School Form

Effective 2022 the completion of all school forms will carry an administrative charge of $10.00. This charge is a flat fee for the two standard forms the office completes for patients that have Asthma and/or Food Allergy (AAP and FARE). If any form or forms are needed outside of the standard package a fee of $10.00 per form will be assessed. The turn time for the standard package and additional forms is 10-12 business days. We are now accepting expedited requests for forms packages. The timeframes and associated costs are $25.00 for 3 business days, $50.00 for 2 business days and $75.00 for same day return.

Turn time on forms will begin once a forms request is received with all requested information including payment information. If the information provided is inaccurate or incomplete this will delay our ability to begin work on the forms which will impact your turn time. Forms requests received after 10:00 am eastern will be considered received the following business day.

All requested information includes all fields on the school form request completed with accurate and up to date information. It also includes payment details. Our office will not gather details for the forms request from various sources nor will they take payment information over the phone. Business days are considered days the office is open. Return of forms will be electronic unless mailed hard copies are requested.

If you do not wish to submit your school forms request through our website, you can download the form request and mail it to our office with payment.

Please note if you have not been seen by Dr. Mayer in the last calendar year, we will not be able to complete your forms until you have been seen in the office or virtually if applicable. Forms needed other than AAP and FARE are to be uploaded with the submission of this request. Photos of forms will not be processed; you must provide a scan of the actual form needed. To ensure each patient’s data is properly collected and reflected on forms our staff cannot process forms requests that are not accompanied by the school forms needed.

If any of the data supplied for the creation of the standard forms package or any additional forms is inaccurate and results in the need for corrections the forms request would be considered new, and the respective fees would apply.

Information needed for completion of all school forms

Requesting Food Allergy Action Plan

yes

Requesting Asthma Management Plan

yes

Patient Name

Date of Birth

Current Weight

Allergens:

Asthma Triggers:

Does the student have Asthma

yes

If the student has Asthma, are they on a daily controller medication

yes

Is the student an OIT patient or graduate

yes

Student may self-carry Epinephrine

yes

Student may self-administer Epinephrine

yes

Student may self-carry Albuterol

yes

Forms fees

FARE & AAP standard forms package $10.00

Additional forms needed $10.00/Per Additional Form

Number of additional forms (Please remember to upload additional forms )

Service Levels and fees if applicable

Standard 10-12 business days NO CHARGE

3 business days $25.00

2 business days $50.00

1 business day $75.00

Credit/Debit/HSA

Card Number

Exp Date

CVV

Zip Code

Name on Card

Authorization to charge for services selected above

Upon review of this forms request you will receive a portal message from our staff confirmed receipt and anticipated completion date or requesting additional information. It is your responsibility to monitor your portal for communication from the office and for providing any requested information to resume work on your school forms request.

Please check this box if you would prefer to have the forms mailed to you instead of receiving them via email. Please provide the complete address where you would like your forms mailed. If you select this box and do not provide your address your forms will be emailed. If you do not select this box and provide an address your forms will be emailed.

Address

City

State

Zip Code

Parents/Guardians

The following directive is based on parent/guardian preference on how the schools should respond if a potential or definitive exposure occurs. The decision on how the school should respond cannot be made by your physician or by other staff members of this office and must be made by the parent/guardian. Indicate your preferences below.

Should Epinephrine be given immediately if allergen was LIKELY eaten

yes

Should Epinephrine be given immediately if allergen was DEFINITELY

yes

Contact Name

Contact Number

Contact Email

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We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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