The Jacksonville Lymphedema Clinic 3599 University Blvd, South, Suite 503, Jacksonville, FL Phone Fax

Transcription

1 Dear Sir or Madam, Thank you for selecting the Jacksonville Lymphedema Clinic for your therapy. We are committed to providing you with the most effective therapy possible. To achieve this goal, our multi-disciplined team of therapists, which includes a physician, occupational therapists and licensed massage therapists, are all specially trained and knowledgeable about Lymphedema and its treatment. During your initial appointment, you will be evaluated by our physician, Dr. Rickie P. Sander, who will assess the severity of your swelling to determine an individualized therapy regimen. This regimen will include manual lymph drainage, multi-layered bandaging (if appropriate), exercises, and instructions on how to care for your limb(s). Treatments are generally scheduled on consecutive days, at the same time each day, to ensure consistency with your therapy. Our therapists will be available to answer your questions about the therapy during the intensive program and will also consult with your physician and provide him or her with follow-up progress reports. Office staff will also process your insurance forms for you. It is the policy of The Jacksonville Lymphedema Clinic that each patient notifies his or her therapist within 24 hours of scheduled appointment. Each cancelled appointment will result in a fee of $25.00, which is non-billable by Insurance and collected on the next visit. In addition, a maximum of three (3) non-emergent cancellations will result in discontinued services from The Jacksonville Lymphedema Clinic. A discharge letter will be sent to your referring physician and continued services with be rendered upon re-evaluation only. Thank you, Beverly Mixon JLC Office Manager Patient initials:

2 Lymphedema is a chronic swelling that is caused by an impairment of the lymphatic system. The condition usually gets worse without treatment, and side effects can include a higher risk of infections and skin changes that may include dryness, thickening, discoloration, or weeping of fluid through the skin, among others. The treatment for lymphedema does not cure the impairments to the lymphatic system, but it can improve the symptoms. The overall goal of treatment is not just to reduce the swelling, but to teach you how to manage the symptoms at home. Treatment for lymphedema has several components; manual lymph drainage, compression, skin care, and exercise. Manual lymph drainage is a type of light massage to help direct fluid from swollen areas to other parts of the body that can absorb and process the fluid. To keep the fluid from returning, compression is applied to the swollen area. Skin care is also an important part of treatment in order to reduce the risk of infection. Light exercise is important because muscle contractions squeeze lymph vessels, which helps to pump the fluid out of the swollen area. The compression that is typically used during the course of treatment is bandaging. Bandaging consists of a stockinette to absorb sweat and make the bandages more breathable, padding to protect boney areas and evenly distribute the compression, and short-stretch bandages to apply the compression. The bandages should be worn about 22 hours a day, for best results. As the swollen area reduces in size, it is important to reapply the bandages to fit the smaller limb and maintain the proper compression. Otherwise, the compression becomes too loose and allows the limb to refill with fluid, which is why treatment is done five days a week for best results. If five days a week is too frequent to fit your schedule, progress can still be made with three sessions a week, but the progress may be slower. If the swelling is mild or if you become proficient with completing the manual lymph drainage and bandaging at home, the frequency of visits may be lowered without hampering progress. Once the maximum reduction of volume has been achieved, many people choose to use garments such as compression hose or sleeves instead of bandaging. Your lymphedema therapist will discuss the compression options with you as part of treatment. The first treatment session will include detailed education about lymphedema and how treatment improves symptoms, but if you have any questions beforehand, please feel free to contact us at (904) Thank you, The Jacksonville Lymphedema Clinic team

3 ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBLITES Today s Date: Patient s Last Name: First: MI: Home Phone # Cell Phone # Home Address: Mailing Address: City: State: Zip: City: State: Zip: DOB: Age: Male/Female SSN#: Married: Single: Divorced: Widowed: Other: Employers Name: Phone: Employer Address: Occupation: Spouse: Phone: Spouse s Employer s Name: Phone: Emergency Contact if not spouse: Relationship: Phone #: Cell Phone #: Referring Physician: Primary Care Physician: Primary Insurance: Insured s Name: Secondary Insurance: Insured s Name: 1. I understand that I am responsible for charges not covered or reimbursed by the above agents. I agree, in the event of nonpayment to assume the cost of interest, collection and legal actions (if required). 2. I authorize my insurance carrier to release information regarding my coverage to Jacksonville Lymphedema Clinic. I also authorize agents of any hospital, treatment center or previous physicians to furnish Jacksonville Lymphedema Clinic copies of any records of my medical history, services or treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation agency, or any physician, insurance carrier, suppliers/vendors for needed DME and garments. I also agree to a review of my records for purpose of internal audits, research and quality assurance revises with Jacksonville Lymphedema Clinic. 3. My rights to payment for all supplies, physician/therapist services including major medical benefits are hereby assigned to Jacksonville Lymphedema Clinic. This agreement covers any and all benefits under Medicare, other government sponsored programs, and private insurance and any other health plan acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for service. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or my representative, I will endorse such payment to Jacksonville Lymphedema Clinic. THIS AGREEMENT/CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING I have read the above statement and accept the terms. A copy of this statement is considered the same as original. PATIENT SIGNATURE:

4 Compression Bandages Compression bandaging is an integral part of lymphedema therapy. You will be required to purchase one set of compression bandages that will be reapplied during each therapy session, however we recommend that you purchase two sets for sanitary purposes to be able to wash one set while wearing the other. A full set of compression bandages for an upper extremity (arm) average about $82.00 per extremity and increase depending on size. A full set of compression bandages for a lower extremity (leg) average about $ per extremity and increase depending on size. Most insurance carriers (including Medicare) do not reimburse for bandages therefore the responsibility for payment belongs to the patient. Our policy is to avoid placing a financial hardship on any patient; however the bandages are sold to you at our cost and cannot be discounted or written off. We thank you for your patronage. Authorization for photographs As part of documentation your response to therapy, we prefer to take photographs as a visual indicator of the reduction of fluid and subsequent decrease in swelling of the affected limb/area. Photographs will be taken before, during, and at the end of treatment. All photographs will be kept strictly confidential and will never be released to any party other than your Primary Care Physician, your referring physician and/or your insurance provider, if requested. Photographs will only be taken of your affected limb or area (i.e., arms, legs, etc.) and the opposite limb to offer comparison. Your face will not be photographed. Photographs will be identified by placing a placard with your name and the date in the area to be captured. The photographs will become part of your clinic medical file. I hereby authorize the Jacksonville Lymphedema Clinic to compile a visual record of my condition with the understanding that the photographs will be kept strictly confidential as part of my medical file. Name Date

5 Date: Patient History Last Name: First Name: MI: Which area(s) has the lymphedema (swelling)? Check all that apply. Left Arm Left Leg Neck Right Arm Right Leg Chest Other (please explain) When did your lymphedema first occur? Have you ever had cellulitis in the affected area? If so, how many times? Were you prescribed antibiotics for the infection/cellulitis? If so, what antibiotic and for how long? Do you take prophylactic (precautionary) antibiotics? If so, what antibiotic and how often? Do you take a diuretic (water pill) for the swelling/lymphedema? If so, which diuretic and how often?

6 Do you take a diuretic (water pill) for the swelling/lymphedema? If so, which diuretic and how often? Does anyone in your family have lymphedema? Have you had prior treatment for lymphedema? (Check all that apply) Manual Lymphatic Drainage (massage) Compression Garment Custom Fitted or Ready Made Brand: Compression Class (mmhg): Style: How often do you wear the garment? Bandaging of the affected limb Remedial movement exercises, how often? Respiration Therapy (breathing exercises), how often? Pneumatic Pump Manufacturer: Frequency of Use: Pressure Setting: Are you currently receiving ANY home-health care or assistance? If so, what agency and how often?

7 Name: D.O.B.: Date: Medical History Please select any condition(s) that apply to your medical history: Angina Arthritis Cancer Colitis Congestive Heart Failure COPD Coronary Artery Disease Diabetes Gastric Reflux Glaucoma Heart Disease Hepatitis High/Low Blood Pressure Jaundice Renal Insufficiency Stroke TB Thyroid Disease Ulcer Venous Insufficiency Other Are you pregnant? Yes No Are you experiencing pain? If so, please describe: Are you currently undergoing chemotherapy or radiation therapy? If so, please describe. Surgical History Please check all that apply: Date Date Arthroscopic Surgery Axillary Back Surgery Cholecystectomy Coronary Bypass Gall Bladder Hand Surgery Joint Replacement Mastectomy Neck Surgery Tonsil/Adenoid Surgery Eye Surgery Foot Surgery Other

8 Medical Information Please list all current medications: Please list all drug allergies: Reactions: Family History Please check all that apply: Father Mother Siblings Children Grandparents Arthritis Cancer Diabetes Epilepsy Heart Disease High Blood Pressure Kidney Disease Lymphedema Osteoporosis Psoriasis Stroke Thyroid Disease Other

9 Social History Have you ever smoked cigarettes? Yes No Do you currently smoke? Yes No If yes, how many cigarettes do you smoke per day? (1 pack= 20 cigarettes) Less than one pack One pack 3 packs More than 3 packs 2 packs How long have you been a smoker? Less than a year 1-5 years 6-10 years years years More than 20 years Do you drink alcohol? No Yes, but no more than once a month Yes, several drinks a week Yes, one drink a day Yes, more than one drink a day Do you regularly drink beverages containing caffeine? No Yes, but not everyday Yes, 2 cups per day Yes, 3 or more cups per day What is your activity level? Vigorous Moderate Sedentary Type of exercise: Frequency of exercise: Daily Weekly 2-3 times per week 3-4 times per week Occasionally Never

10 REVIEW OF SYSTEMS Please check all that apply. Constitutional Chills Fatigue Fever Malaise Night Sweats Weakness Weight Gain Weight Loss Metabolic / Endocrine Cold Intolerant Hair Loss Heat Intolerant Diabetes Thyroid Problems Musculoskeletal Arthritis Joint Pains Spasms Back Pain Neurological Difficulty Walking Dizziness Poor Coordination Memory Loss Muscle Weakness Paresthesia Seizures Tremors Numbness Genitourinary Dysuria Frequent Urination Hematuria Urge Incontinence Stress Incontinence Cardiovascular Chest Pain Cyanosis Heart Murmur Irregular Heartbeat /Palpitations Leg Swelling Syncope Hypertension HEENT Blurred Vision Double Vision Dysphagia Ear Drainage Facial Pain Headache Hearing Loss Hoarseness Nasal Congestion Ringing in Ears Vertigo Vision Loss Psychiatric Anxiety Depression Insomnia Hematologic Bleeding Bruising Anemia Integumentary Contact Allergy Itchy Skin Rash Skin Infections Skin Lesions Gastrointestinal Abdominal Pain Constipation Black Tarry Stools Diarrhea Heartburn Jaundice Loss of Appetite Nausea Vomiting Respiratory Chest Pain Cough Dyspnea Recent Infection Known TB exposure Wheezing Shortness of Breath Immunological Asthma Bee Sting Allergies Contact Dermatitis Environmental Allergies Food Allergies Seasonal Allergies