Baptist South Medical Center • 14546 Old St. Augustine Rd., Ste 101 • Jacksonville, FL 32258

Orange Park Office • 2140 Kingsley Avenue, Suite 1 • Orange Park, FL 32073

Phone (904) 298-1800 • Fax (904) 298-1802

Dear New Patients,

Welcome to Watkins Allergy and Asthma Clinic! We are genuinely pleased that you have

chosen us for your allergy and asthma care. Our practice realizes the importance of referrals and

we value them greatly. We are always excited to see new faces coming through our door!

At your first appointment, your doctor will complete a comprehensive examination. This

includes a complete review of your medical history, all necessary blood/lab work, medications,

previous allergy/asthma testing, x-rays and breathing test.

If your appointment includes allergy testing, we request you refrain from taking any

antihistamine medication for 4 – 5 days prior to your appointment. However, please continue any

asthma medications. If skin testing is performed, your visit could last up to two and a half hours,

so please plan accordingly. Following this appointment and testing, your doctor will discuss the

findings with you and develop a treatment plan that you are comfortable with.

If you have health insurance, be sure to provide all requested information prior to your

appointment to assist us in the benefit verification process. Payment is expected at the time of the

first visit. If you have any questions about finances please feel free to ask us at any time.

Please be prepared for your appointment by:

bringing in any pertinent medical records

bringing all medicines or a list of all medicines, including dosage

completing the enclosed new patient questionnaire

refraining from taking any antihistamine medications for 4 – 5 days prior to your testing

appointment.

DO NOT stop your Asthma medications

We ask that you make every effort to keep your appointments. If you need to reschedule your

appointment, please call us at least 24 hours prior to your visit.

We very much appreciate your confidence in us and look forward to meeting with you!

Sincerely,

Dr. Raquel Watkins

Baptist South Medical Center • 14546 Old St. Augustine Rd., Ste 101 • Jacksonville, FL 32258

Orange Park Office • 2140 Kingsley Avenue, Suite 1 • Orange Park, FL 32073

Phone (904) 298-1800 • Fax (904) 298-1802

Medications to avoid prior to skin testing Review the following list in detail and follow all instructions. Many patients receive allergy skin testing at

their first office appointment.

Do not use any lotions or creams on your back or upper arms the day of the skin test.

Hold topical steroids on back and upper arms 2 weeks prior to testing.

If on a beta-blocker (type of heart medication) schedule an early morning appointment and do not

take your beta-blocker on the morning of your visit. Be sure to notify Dr. Watkins that you are on

a beta-blocker. Please bring the pill with you as you will be expected to take it once skin testing

has been completed.

Do not hold any inhalers for asthma.

All Antihistamines: Hold 5 days prior to test. This is not a comprehensive list, so please check

with your pharmacist if you are unsure if you are on antihistamines.

Any over the counter cold or allergy medications

Alavert (loratadine)

Allegra (fexofenadine)

Astelin or Astepro nasal spray (azelastine)

Atarax(hydroxyzine)

Benadryl (diphenhydramine)

Brompheniramine

Chlor-Trimeton (chlorpheniramine)

Claritin (loratadine)

Clarinex (desloratadine)

Cyproheptadine

Dimetane-Dimetapp

Dymista

Pataday eye drops

Patanase nasal spray

Phenergan (promethazine)

Tavist (clemastine)

Tussionex (hydrocodone and chlorpheniramine)

Vistaril (hydroxyzine)

Xyzal(levocertirizine)

Zyrtec (cetirizine)

Other medications to avoid for 2 days prior to test: Zantac (ranitidine)

Tagamet (cimetidine)

Pepcid-AC

Singulair (montelukast)

Accolate

Watkins Allergy and Asthma Clinic

Acknowledgement of Receipt of Notice & PHI Disclosure Authorization

Patient’s Full Name Patient’s Date of Birth

1. I hereby authorize Watkins Allergy and Asthma Clinic to use or disclose protected health information (PHI) about

me to the following person(s). Please write “N/A” in any of the 3 fields below if not populated with the name of a

person:

Authorized Individual #1 Authorized Individual #2 Authorized Individual #3

Name

Address

City, State

Zip

Phone

Number

2. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of

persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

3. This authorization expires upon written notice from me, and may be revoked at any time. Revocation must be in

writing and submitted to the following address: Privacy Officer, 4800 Belfort Rd, Jacksonville, FL 32256.

4. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether

I sign this authorization.

5. NOTICE: I acknowledge that I have had the opportunity to review a copy of BGC’s Notice of Privacy Practices

(“Notice”). I understand that I am responsible to read this Notice and notify BGC, in writing, of any request for

restrictions in the use or disclosure of my PHI. I understand BGC has the right to revise this Notice at any time

and will post a copy of the current Notice in the office in a visible location at all times and on their website at

www.borlandgroover.com. BGC will provide me with a copy of its most recent Notice upon my request.

6. I understand the most recent version of this form replaces any previous versions on file in my Watkins Allergy

health record. Previous versions will be voided and PHI release will be based on the current version of this

authorization.

__________________________________________ _______________________________

Signature of Patient Date of

Patient Signature

OR

___________________________________ _________________________ _____________________________

Signature of Patient’s Representative Date of Representative’s

Signature

Description of Authority

to Act for the Patient

A copy of this completed, signed and dated form must be given to the Individual or other signator.

Watkins Allergy and Asthma Clinic Medical Records Release/Request Form

Patient’s Full Name Patient’s Date of Birth

Instructions: This form must be fully completed before being accepted for processing. All fields must be completed – please use “N/A” where

appropriate.

I hereby authorize ☐ Watkins Allergy and Asthma Clinic OR _______________________________________________to disclose protected health

information about me as described below. (Name of provider to obtain records from)

1. Please send my medical records to:

Raquel Watkins MD

Provider Name

904-298-1802

Address Fax Number

City, State Zip Code

2. Authorization expiration date: __________________________________ ,OR when the following event occurs: ☐ 1 year from date signed

3. The specific information that should be disclosed is:

Click

box to

release

this type

of info.

Information Type Approx.

date of

service/

general

time frame

Click

box to

release

this type

of info.

Information Type Approx.

date of

Service/

general

time frame

☐ Laboratory results ☐ X-ray

(body part _______________________________)

☐ Procedure Report please specify procedure

____________________________________)

☐ CT/Pet/MRI Scan

(body part _______________________________)

☐ Office Note/History & Physical ☐ Ultrasound

(body part________________________________)

☐ Pathology ☐ Other – please be specific

(________________________________________)

I specifically request you include any of the following information, if it exists: Psychiatric, alcohol/substance abuse, HIV/AIDS, Sexually transmitted disease

or mental health. ☐ YES, include this information ☐ NO, do not include information

4. I understand that the information disclosed may be subject to re-disclosure by the person or facility receiving it, and would then no longer

be protected by federal privacy regulations.

5. Your care will not be based on your willingness to authorize release of medical records.

6. You have the right to and may revoke this authorization by notifying compliance@bgclinic.com in writing. However, the requestor

understands that any action already taken based on this authorization cannot be reversed, and my revocation will not affect those actions.

7. Purpose/use of the information is ☐ at the request of the individual ☐ treatment ☐ other: _____________________________________

____________________________________________________________

_____________________________________

Signature of Patient

Date of

Patient Signature

OR

__________________________________________ __________________________ ___________________________________

Signature of Patient’s Representative Date of

Patient Representative’s Signature

Description of Authority

to Act for the Patient

A copy of this completed form must be provided to the requestor.

Financial Policy

Dear Patient/ Patient Guardian,

Thank you for choosing Watkins Allergy & Asthma Clinic for your health care needs. Our primary concern is centered

on you, our patient, and that you receive the proper care needed to restore your health. Our financial policy is a necessary

part of assuring the financial resources required to maintain the vital health care facility for our patients and our

community. Therefore, we ask that you please read the following and sign prior to having your appointment.

Payments are due at the time services are rendered, unless prior arrangements have been made with our billing

department. Co-payments and deductibles are due at the time services are rendered. We gladly accept cash, checks

and for your convenience, we accept all major credit cards. All returned checks are subject to a $25.00 returned check

fee.

Please ensure that we have a copy of your most current insurance card on file, and that if any changes occur with your

insurance that we are notified immediately. This will ensure that we have acquired the proper authorization required by

your health care plan, to perform your procedure. It is important that you understand we view your insurance as a contract

between you, your employer and the insurance company, therefore, we cannot become involved in disputes between you

and your insurance company regarding deductibles, co-payments, covered charges, etc. Our services are rendered to

you, not your insurance company.

We participate in many different health plans and programs and currently accept assignment with Medicare, and

participate with most managed care plans. Also, not all services are a covered benefit. Please be aware of your benefit

package with your insurance company. Any charges not paid by your insurance company are solely your

responsibility. We file secondary insurances as a courtesy. If your secondary insurance fails to remit payment within

60 days, we require you to pay the remaining balance.

Patient statements are mailed monthly. Please pay promptly upon receiving statement. All outstanding balances older

than 90 days will be subject to review and forwarded to our collection department where an additional $25.00 collection

fee will be added to the account balance and forwarded to the Credit Bureau. We understand that temporary financial

problems may affect timely payment. We encourage you to contact our billing department to make arrangements.

Again, thank you for choosing us for your health care needs, and we appreciate the opportunity to serve you.

Patient/ Parent or Guardian’s Signature: ____________________________________________ Date: ___________

Patient/ Parent or Guardian’s Name (Please Print):_____________________________________

By my signature, I indicate that I have read this policy and agree to its provision.

Baptist South Medical Center • 14546 Old St. Augustine Rd., Ste 101 • Jacksonville, FL 32258

Orange Park Office • 2140 Kingsley Avenue, Suite 1 • Orange Park, FL 32073

Phone (904) 298-1800 • Fax (904) 298-1802

Baptist South Medical Center • 14546 Old St. Augustine Rd., Ste 101 • Jacksonville, FL 32258

Orange Park Office • 2140 Kingsley Avenue, Suite 1 • Orange Park, FL 32073

Phone (904) 298-1800 • Fax (904) 298-1802

Welcome to Watkins Allergy and Asthma Clinic, where we are committed to providing you with the best

possible care. Please take a few minutes to read this letter to familiarize yourself with our office policy.

Refills: Call your pharmacy and they will send a request directly to our office. Please allow 48-72

hours for refills. Therefore, you should call your pharmacy 1 week prior to needing your refill. Refills

are not considered an emergency and will be done only during normal business hours.

Forms: There will be a $15.00 Fee for processing all forms and letters which includes but is not limited

to: FMLA, School forms, etc.

No show: Please be aware if you do not show up for your scheduled appointment, you may be charged a

$30.00 No Show Fee. You may also be charged this fee if you do not give us a 24 hour notice of

cancellation. This fee is not covered by your insurance. Three or more cancellations or no-shows can

result in dismissal from the practice.

Outstanding Balance: Any balance from previous visits MUST be paid before next follow up visit.

Late Arrival: Please help us maintain our schedule by being on time for your appointment. If you arrive

15 minutes late, you will be given the option to wait if we can fit you in or reschedule your

appointment.

Results: If you have lab work or diagnostic testing done and do not have a follow up appointment

scheduled with your physician, please call the office for an appointment. If you have not heard from the

office, do not assume all results are normal.

____________________________________ ____________________________________

Print Name Sign Name

____________________________________ ____________________________________

DOB Date

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