Venom Consent Packet

• Patient financial responsibility-Venom shots
• Immunotherapy financial consent form
• Immunotherapy (Allergy shot) consent
• Shot patient emergency contract information

Once the Venom Consents are received

1. The physician places the order for your immunotherapy.
2. The order is approved, and serum is made.
3. The office will contact you to set up the first allergy shot appointment and verify the office you will be receiving your injections.

PATIENT FINANCIAL RESPONSIBILITY – VENOM SHOTS

Your physician is recommending allergen immunotherapy for you or your child. Please call your insurance company at the Member Services phone number to confirm that this is a covered benefit. Provide the following highlighted procedure codes to the insurance company

Venom Shot Procedure Codes

95180 Venom desensitization

95117 - Administration Injection

95145 - Single Stinging Insect Venom

95146 - Two Single Stinging Insect Venom

95147 - Three Single Stinging Insect Venom

95148 - Four Single Stinging Insect Venom

95149 - Five Single Stinging Insect Venom

This form must be completed, signed and return the our office prior to starting immunotherapy.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Facts About Immunotherapy

Venom shots are an attempt to build a tolerance to the insect venom to which you are allergic

Reactions may occur. There are two types.

A LOCAL reaction usually occurs within 20 minutes after the injection although it may occur later. A local reaction is redness, swelling and itchiness at the site of the injection beyond what you should have from a mosquito bite.

A SYSTEMIC reaction usually occurs within 30 minutes after the injection. The symptoms of a systemic reaction include itchy eyes, itchy ears and throat, coughing, congestion, sneezing, throat tightness and hives. It is potentially life threatening and should be reported AS SOON AS POSSIBLE.

As systemic reactions are possible, all patients are required to wait 30 minutes in the waiting room. UNDER NO CIRCUMSTANCES CAN VENOM SHOTS BE GIVEN AT HOME. Should symptoms of a systemic reaction occur, emergency medical treatment should be sought, either in our office or at the nearest medical facility. After you are stabilized, our office should be notified.

Local reactions on the arm are used as a guide for further treatment and therefore should be reported to the nurse prior to administration of the next shot. Should they become uncomfortable, ice packs and antihistamine can be given. ALL PATIENTS SHOULD CARRY AN ANTIHISTAMINE WITH THEM ON THE DAY OF THE SHOT AND IF YOU HAVE ASTHMA YOU SHOULD CARRY YOUR INHALER WITH YOU. We would like you to be committed to getting your shots on time. If you need to be away for an extended period of time, let us know and arrangements may be made for you to receive your immunotherapy elsewhere.

Once you are receiving your venom shots monthly or every 6 weeks, you are expected to see your allergist on a regular basis at least once per year. Please notify the nurse or physician if you are taking any new medications, specifically beta-blockers, which are used in the treatment of high blood pressure, heart disease and migraine headaches. Patients on beta-blockers should not receive immunotherapy.

Venom patients should have an Epi-Pen or Epinephrine Kit. (Please make sure the expiration dates are good.)

You or your insurance will be charged at the time of shots for the administration of the shot; extracts are billed separately for some insurance programs. Please call us at (860) 232-9911 if you should have any questions.

Desensitization consists of gradual increases on the strength and dose of venom until a maintenance level of 1cc of mcgm/ml is achieved. Although treatment can vary due to an individual patient’s sensitivity, the usual treatment is as follows:

Treatment Schedule

Questions regarding venom treatment may be directed to our lab nurses in the West Hartford office at (860) 232-9911

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Venom Immunotherapy Financial Consent Form

Insurance plans are highly variable regarding coverage of immunotherapy treatment. There are two costs to consider. The first cost is for the “antigen” or “extract” (95145, 95146, 95147, 95148, 95149). The antigen (extract) is prepared at Ct Asthma & Allergy LLC from a recipe your physician has written. Your second cost is for the administration of the injections (95180, 95115 or 95117).

Ct Asthma & Allergy recommends that you contact your insurance carrier to find out your specific coverage. It is important to understand your insurance coverage and know your responsibility of the cost. Some Insurance plans cover immunotherapy in full, while other plans have associated deductibles, co-insurances and co-pays.

➢ I acknowledge, with my signature, that I am authorizing Ct Asthma & Allergy LLC to bill my insurance company for the allergen extracts made for me/my child. I understand that, if I decide not to initiate allergen immunotherapy after the extracts have been made, I am still responsible for the cost of the extract. I acknowledge that any costs incurred for this method of treatment that is not covered by my insurance carrier, such as deductibles, co-insurances, or co-pays will be my responsibility. I also acknowledge that my allergen extracts will not be prepared until this signed consent is returned to Ct Asthma & Allergy LLC.

I authorize the preparation and billing of the allergen extract

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Shot Patient Emergency Contact Information