Sample worksheets from various websites like Autism and Health, Healthcare Information Guide, and HealthyTransitionsNY.org.
Includes: Sample filled out making appointments worksheet, sample filled out appointment scheduler, sample filled out visit planner, sample image of calendar and insurance/benefit card, blank calendar and insurance/benefit card for practice, insurance/benefit card sample, POLDCARTS reference (what to write down or think about before a visit for a specific problem), sample HIPAA form, sample, sample consent to treat form, sample accommodation request for healthcare appointments.
7. Appointment Scheduler
www.HealthyTransitionsNY.org
New York State Institute for Health Transition Training
1
Completed by: Date:
Have ready:
Calendar
Your Insurance Card/Number
Doctor’s Name and Phone Number
Call:
Hello, my name is: (your name)
I would like to schedule an appointment with: (doctor’s name)
Because: (reason you want to see doctor. For example, check-up, headache)
What times and dates are available?
Check calendar: if not good say “Would you have another time available?”
Repeat back:
My appointment is with:
Dr. (name of doctor)
on: (date and time)
If you need accommodations (for example: lift, translator) tell secretary
Thank you.
Mark calendar:
Name of Doctor:
Date and time:
You May Be Asked:
• To say your name again
• Your date of birth
• Last time you saw your doctor
• Your Insurance Number
• Your Phone Number
After you hang up: make sure to schedule transportation!
Dr. House
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Dr. House
I have been very sleepy during the day the last three weeks.
Tuesdays and Thursdays after 1:00 PM
House
Friday, June 3rd at 11:00 A.M.
6/3/22 11:00 AM CST
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8. Visit Planner
www.HealthyTransitionsNY.org
New York State Institute for Health Transition Training
1
Completed by: Date:
MY APPOINTMENT
Doctor’s name:
Appointment Date/Time:
Transportation I will use:
WHAT I NEED TO BRING
Insurance card
My medications in a brown bag
Transition Information Form
FILL IN BEFORE APPOINTMENT:
Why am I going to doctor?
When does it bother me?
What do I want to know?
Do I need prescription refills?
OTHER QUESTIONS (check if you would like to discuss)
Eating healthy Dental health
Exercise Job
Sexual health Communication
Mental health Pain
FILL IN AT APPOINTMENT
What do I need to do?
Who will help me?
Reasons to call my doctor:
Do I have new prescriptions?
Were all my questions answered?
My next appointment is:
DO AFTER MY APPOINTMENT
My Healthy Transitions Score:
My Healthy Transitions Plan:
June 3rd at 11:00 AM
Pick up my prescription from the X pharmacy.
Princess Aurora June 1,
Dr. Gregory House
I will drive
I have been sleeping during most of the day.
The last 3 weeks.
Why am I sleeping so much?
Not applicable
If my symptoms don't improve after 2 weeks of starting the med.
Yes.
Yes.
I am supposed to call if my symptoms don't improve or get worse.
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9.
10.
11.
12. POLDCARTS
P
(Previous history) Have you ever
experienced this before?
O
(Onset) When did you first notice this?
When did it start?
L
(Location) Can you point to where it
bothers you the most?
D
(Duration) How long does it last? (is it
intermittent, constant….)
C
(Characteristic) Can you describe it?
(sharp, dull, stabbing, pins and
needles…)
A (Aggravates) What makes it worse?
R (Relief) What makes it better?
T
(Time) When do you notice it? (in the
morning/all day, just at night…)
S
(Scale) On a scale of 0-5 how would
you describe it?
13.
14.
15. Sent Via Email/Mail/Fax: Insert address
___________, 2021
Doctor Name
Address
Email
Re: Request for Reasonable Accommodation to ensure effective communication
Dear Medical Provider,
As a patient with a disability, I am requesting a reasonable accommodation to ensure
effective communication between you (including staff) and myself. I am a qualified individual
with a disability, as defined by the Americans with Disability Act (ADA).
Because of my disability, I need the following accommodations:
• Sample accommodation #1: Extended face to face time with provider if requested
at the time of making the appointment, or multiple visits within the same limited
time span (i.e. same week or month if necessary),
• Sample accommodation #2: To call a third party (such as a family member) during
the visit if needed for effective communication,
• Accommodation #3
According to Title III of the Americans with Disabilities Act (ADA), a public
accommodation may not discriminate against an individual with a disability in the operation of a
place of public accommodation. Individuals with disabilities may not be denied full and equal
enjoyment of the "goods, services, facilities, privileges, advantages, or accommodations" offered
by a place of public accommodation. In order to provide equal access, a public accommodation is
required to make available appropriate services where necessary to ensure effective
communication.
My requested accommodations are necessary for my health and safety. Sometimes, treating
persons with a disability exactly the same as others has a discriminatory or exclusionary effect.
This accommodation will enable me to have an equal opportunity to communicate effectively with
my healthcare providers. Please let me know what, if any, additional information you need
regarding my health in order to better understand my disability and the limitations it imposes.
Please keep this request for accommodation confidential, as required by federal law. Thank
you for your time and consideration.
Sincerely,
First Name Last Name
Physical address
Street name, city, state, zip code