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, and sample consent to treat form.

1. M A K I N G A N A P P O I N T M E N T
© August 2012 Academic Autistic Spectrum Partnership in Research and Education
http://aaspire.org
1
Making an Appointment Worksheet
This worksheet walks through the steps of making a healthcare
appointment. It has lines to write in information that you might want
handy while making the appointment. It also has lines to write in
information the office staff might tell you, like the day and time of the
appointment. The parts in italic can be used as a script to be used in
conversation, if desired. Some things on this worksheet may not apply
to you. That’s OK; just ignore those parts.
1. Making an appointment is usually done by telephone, in person, or,
if available, through a secure electronic messaging system
(example: MyChart). You may also have arranged a special way of
contacting the office previously. Start by contacting the office.
The contact information for the provider's office is (use the option
that applies to you):
• Telephone ____________________
• Web address and login information for secure messaging system
______________________________________________________
• Other contact information ________________________________
• The provider’s name is: __________________________________
(123) 867-5309
www.mydoctorwebsite.com
Dr. Gregory House

2. M A K I N G A N A P P O I N T M E N T
© August 2012 Academic Autistic Spectrum Partnership in Research and Education
http://aaspire.org
2
Hello, my name is __________ and I’m calling to make an
appointment with _______________.
2. When you contact the provider’s office, tell them what the
appointment is for. You may need to give details to a nurse, medical
assistant or scheduler–they are an important part of a team and will
keep your information confidential.
NOTE: If you are making your first appointment with a new provider,
tell them you want to make a new patient appointment. See
section below for additional information you may need.
______________________________________________________
______________________________________________________
3. Have your (or your supporters’) contact information available in case
the office needs to call you back. The office may not ask for this
information, but it’s good to have just in case.
If the office needs to contact me back, they should contact:
•
• Telephone __________________________
• Other ______________________________
Dr. House
______________________________________________________
(123) 634-5789
Name ______________________________
Princess Aurora
The reason that I am making the appointment is:
I sleep pretty much constantly during the day for the last three weeks.
Princess Aurora, Nickname: Briar Rose

3. M A K I N G A N A P P O I N T M E N T
© August 2012 Academic Autistic Spectrum Partnership in Research and Education
http://aaspire.org
3
4. Know your own schedule / availability; if applicable, know the
availability of the person who will support you and make sure your
schedules work together.
The days and times I am free for an appointment are:
______________________________________________________
______________________________________________________
5. Then there will probably be a conversation next about scheduling.
By the end of the conversation, you should be able to confirm the
date and time of the appointment, and have an estimate of about
how long the appointment is likely to take.
The date and time of my appointment is ______________________.
The appointment will take about __________ (hours or minutes). Is
that correct?
6. Make sure you know the location of the appointment.
The location of my appointment is:
• Street Address: _____________________________________
• Building: __________________________________________
• Floor, suite number, or room number: ___________________
• City or Town: ________________________________________
1
Mondays, Thursdays, Fridays after 1:00 PM
June 3rd at 11:AM
45 minutes
221B Baker Street
Suite 123
London

4. M A K I N G A N A P P O I N T M E N T
© August 2012 Academic Autistic Spectrum Partnership in Research and Education
http://aaspire.org
4
Is that correct?
7. Make sure you know the name of the provider you will be seeing.
8. Make sure you know about anything special you need to bring or do.
Examples: 1) If the provider wants to do a cholesterol test at your
appointment, you might need to fast before the appointment. 2) If
it’s a new patient visit, the provider might want you to bring any
medical records you have.
Is there anything special I should do to prepare for this visit, or
anything special I should bring with me to this visit?
_____
______________________________________________________
______________________________________________________
if you are making a first appointment with a new
healthcare provider
The office staff may ask you for additional information. It may be
useful to have this information handy in case they do.
Dr. House
________________________. Is that correct?
Just to confi
firm, the name of the provider I’ll be seeing is
I need to bring a list of my prescription medications and my insurance card.___
Text
Information to have available when making a fifirst
appointment with a new healthcare provider:
Insurance card (if you have insurance), your birthdate, times/days
you are available, and the name of your provider if you have one.

5. M A K I N G A N A P P O I N T M E N T
© August 2012 Academic Autistic Spectrum Partnership in Research and Education
http://aaspire.org
5
• Name _____________________________________________
• Telephone Number: __________________________________
• Other (alternative to telephone) _________________________
________________________________________________________
11. Mailing address for sending forms or other papers through the
mail:
• Number and Street: ___________________________________
• City or Town: ________________________________________
• Zip Code: _________________
You may also have some additional questions for the office staff, or
things you want to learn about the clinic or provider.
12. If you have any questions about the new provider that haven’t
been answered, ask them now. Examples: Is the provider taking
new patients? Do you accept my insurance? Are you open evening
hours? See Tips for Finding a Provider for more examples.
9. Who and to what number the reminder call should be directed:
(123) 634-5789
10. If you have health insurance, who your insurance provider is:
United-Cares-A-Lot
Name __ _____________________________
Princess Aurora, Nickname: Briar Rose
PrincessAurora@Enchanted.com
1234 King Stephen Street
Forbidden Mountain
3141

6. M A K I N G A N A P P O I N T M E N T
© August 2012 Academic Autistic Spectrum Partnership in Research and Education
http://aaspire.org
6
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
13. If desired, ask if the office can send you the new patient forms to
fill out in advance.
Could you please mail me the new patient forms so I can fill them
out in advance?
14. Consider discussing accommodation needs related to facilities, if
you have them. For example, exploring waiting room options,
accommodating sensory needs, or finding out if it’s OK to visit the
office before the appointment or to take pictures of the office before
the appointment.
I have a disability that can make it hard to manage the office. I’m
wondering if it would be possible to:
______________________________________________________
Be text messaged when I am being called back to the patient room
so I can wear my noise cancelling headphones.
_____________________________________________________
______________________________________________________

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
✔
✔
✔
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
✔
✔

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.
✔
✔
✔

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?