Mid State ENT

Consent for Allergy Testing and Treatment

I understand that allergy skin testing and immunotherapeutic treatment is a form of allergy treatment that has certain advantages and disadvantages. The advantages of immunotherapy are that oftentimes the need for medications can be reduced and/or eliminated and that otherwise uncontrollable symptoms may be better controlled.

I also understand that any form of medical treatment may be ineffective including this form of allergy therapy. I am aware of the adverse side effects such as itchy eyes, nose, or throat; nasal congestion, runny nose, tightness in throat or chest; generalized itching; and anaphylactic shock (a severe drop in blood pressure with swelling of various structures of the body including possible swelling of the airway).

I have informed the allergy nurse and physician of all medications I am currently taking or have taken recently. This includes any eye drops, blood pressure medication, steroids (Prednisone, Medrol Dose Pack), antidepressants, and all allergy medications. If I neglect to inform them of such medications, I understand that there may be side effects when performing the allergy test and/or allergy injections.

I understand that the discontinuing allergy injections or taking the injections irregularly may result in worsening of my allergy symptoms and/or trigger some of the above-mentioned reactions when given a shot.

I have read the patient information packet and understand it. The opportunity has been provided for me to ask questions regarding the potential side effects of allergy skin testing, and have answered to my satisfaction. I understand that every precaution consistent with the best medical practice will be carried out to protect me against any reaction to testing.

I give my consent for allergy testing and immunotherapy with full knowledge of the above information.

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Patient Name (Print) Signature of Patient or Legally Responsible Party

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Date Witness

Mid State ENT - History of Allergy Symptoms

Please list your current medications, including any over-the-counter:______

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List all allergy symptoms:______

When did these symptoms develop?______

Are these symptoms seasonal or perennial?______If seasonal, which seasons?______

Is there anything else that triggers allergy symptoms (i.e. weather, home, school office, animals, smoke)? ______

Have you ever been tested for allergies? ______If yes, when did you have testing and what did you react to?______

Did you receive allergy treatment, and how long were you on injections? ______

How long have you lived in Tennessee?______Where did you move here from?______

Have your allergy symptoms worsened since living here?______

Do you own pets? ______If yes, how many? ______Indoor or outdoor? ______Do your allergy symptoms worsen around when around cats, dogs, etc.?______

Do you have asthma, or have you ever had to go to the ER because of asthma______Is there any chance that you are pregnant? ______

Did you stop taking all antihistamines, betablockers, and tricyclic antidepressants as directed by your physician prior to today’s testing? ______

______Patient Name (Print) Patient Signature or Legal Responsible Party

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Date

Mid State ENT - Advanced Beneficiary Notice

There is a chance that your insurance may not pay for the item(s) or service(s) that are described below. Insurance does not pay for all of your healthcare costs. Insurance only pays for covered items and services that they determine as covered services according to your insurance policy. The fact that insurance may not pay for a particular item or service does not mean that you should not receive it. Your physician has prescribed this/these services as part of your overall diagnosis/treatment for your symptoms. Failure to comply with your physician’s orders may affect your treatment options.

Percutaneous Skin Testing
Intradermal Skin Testing
Allergy Extract
Allergy Injections

Insurance may not pay for these services because:

  • Insurance deems this as not medically necessary.
  • Insurance deems this as experimental.
  • Insurance defines this as a non-covered item or service.

Please mark one of the following:

______OPTION 1. YES, I want to receive these items or services. I understand that my insurance will not decide whether to pay unless I receive these items or services. Please submit my claim to my insurance. I understand that you may bill me for items or services and that I may have to pay the bill while my insurance is making its decision. If my insurance does pay, you will refund me any payments I made to you that are due to me. If my insurance denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand I can appeal my insurance’s decision.

______OPTION 2. NO, I have decided not to receive these items or services. I will not receive these items or services. I understand that you will not be able to submit a claim to my insurance and that I will not be able to appeal the opinion if my insurance won’t pay.

The insurance benefits we receive at our office for your allergy tests are not a “guarantee of coverage or payment” by your insurance company. You are ultimately responsible for the charges if the insurance company fails to pay for the tests in part or its entirety. Charges can be up to $1500.
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Patient Name (Print) Patient Signature or Legal Responsible Party

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Date Witness