tampa criminal attorney

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Dear New Patient,
We have enclosed your new patient paperwork with this letter. Please complete the
forms in their entirety. Please bring the paperwork with you to your appointment on
@ .
On the day of your appointment, please bring with you:
• Your insurance cards for both medical and dental.
• Photo identification (preferably driver’s license).
• A list of all prescription medicines and over the counter medicines you are
taking.
Due to limited waiting room space, please arrive no earlier than 15 minutes before your
appointment. Please understand that we are a surgery office and try to run on time but
emergencies do happen.
Thank you for choosing Ryan Green MD, DDS as your Oral Surgeon, and we look forward to
meeting you. If you have any questions prior to your appointment, call us at (325) 232-8939.
Thank you.
PATIENT REGISTRATION
NAME______________________________________________________________________DATE____________________________
DOB______________________ AGE__________________ SEX (male) (female) MARITAL STATUS (M) (S) (D)
SS#__________________________________________ E-MAIL ADDRESS________________________________________________
ADDRESS____________________________________________________________________________________________________
Street City State Zip Code
PHONE NO. ( )_________________ ( )_________________ ( )__________________ ( ) _____________________
Home Work Cell Other
EMPLOYER__________________________________________________________________________________________________
Name Address Phone no.
PARENT/LEGAL GUARDIAN (if minor):_________________________________________PHONE:______________________________
WHOM MAY WE THANK FOR REFERRING YOU? (dentist, physician, friend, etc.) ____________________________________________
CONTACT PERSON NOT LIVING WITH YOU__________________________________________________________________________
Name Phone no.
WOULD YOU LIKE FOR US TO BILL YOUR INSURANCE? ���YES ��� NO
PRIMARY DENTAL INSURANCE PRIMARY MEDICAL INSURANCE
INS. CO.__________________________________________ INS. CO.___________________________________________
ADDRESS_________________________________________ ADDRESS__________________________________________
_________________________________________________ _________________________________________________
PHONE NO._______________________________________ PHONE NO.________________________________________
GROUP #_________________________________________ GROUP # __________________________________________
INSURED’S NAME__________________________________ INSURED’S NAME___________________________________
RELATION__________________SS#____________________ RELATION_____________SS#_________________________
INSURED’S EMPLOYER_______________________________ INSURED’S EMPLOYER_______________________________
INSURED’S DATE OF BIRTH____________________________ INSURED’S DATE OF BIRTH____________________________
PERSON RESPONSIBLE FOR THIS ACCOUNT______________________________________________________________________
ADDRESS________________________________________________________________ PHONE NO._______________________
RESPONSIBLE PARTY’S SS#_________________________ DOB______________________ DL#______________________
I HEREBY AUTHORIZE DR. RYAN GREEN TO PERFORM THE SERVICES THAT ARE NECESSARY IN HIS JUDGEMENT AND ANY
ADDED PROCEDURE WHICH HE MAY DEEM NECESSARY FOR THE ABOVE PATIENT.
____________________________________________________________________________________________________________________
PATIENT'S SIGNATURE OR PARENT OR GUARDIAN'S SIGNATURE (if applicable)
PATIENT HEALTH HISTORY
Patient’s Name Date of Birth Height Weight Date
Answer all questions by circling Yes (Y) or No (N) All responses are kept confidential
1. Are you in good health? ................................................ Y N
2. Has there been any change in your
general health in the past year? .................................... Y N
3. Date of last physical exam
4. Are you now under a physician’s care for
a particular problem?..................................................... Y N
5. Have you ever had any serious illnesses,
operations or hospitalizations? If so, describe:............. Y N
6. DO YOU HAVE OR HAVE YOU EVER HAD:
A. Rheumatic Fever or Rheumatic Heart Disease?.... Y N
B. Congenital Heart Disease? .................................... Y N
C. Cardiovascular Disease (Heart Attack, Heart
Trouble, Heart Murmur, Coronary Artery Disease,
Angina, High Blood Pressure, Stroke, Palpitations,
Heart Surgery, Pacemaker)? ................................. Y N
D. Lung Disease (Asthma, Emphysema, COPD, Chronic
Cough, Bronchitis, Pneumonia, Tuberculosis,
Shortness of Breath, Chest Pain, Severe
Coughing)? ............................................................ Y N
E. Seizures, Convulsions, Epilepsy, Fainting or
Dizziness?.............................................................. Y N
F. Bleeding Disorder, Anemia, Bleeding Tendency,
Blood Transfusion? Do you bruise easily? ............ Y N
G. Liver Disease (Jaundice, Hepatitis)?...................... Y N
H. Kidney Disease? .................................................... Y N
I. Diabetes?............................................................... Y N
J. Thyroid Disease (Goiter)? ...................................... Y N
K. Arthritis?................................................................. Y N
L. Stomach Ulcers or Colitis?..................................... Y N
M. Glaucoma?............................................................. Y N
N. Osteoporosis?........................................................ Y N
O. Implants placed anywhere in your body
(Heart Valve, Pacemaker, Hip, Knee)? .................. Y N
P. Radiation (X-ray) treatment for Cancer? ................ Y N
Q. Clicking or popping of jaw joint, pain near ear,
difficulty opening mouth, grind or clench teeth? ..... Y N
R. Sinus or Nasal problems? ...................................... Y N
S. Any disease, drug or transplant operation
that has depressed your immune system?............. Y N
T. Sleep apnea?.......................................................... Y
N
7. ARE YOU USING ANY OF THE FOLLOWING:
A. Antibiotics?............................................................. Y N
B. Anticoagulants (Blood Thinners)? .......................... Y N
C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? Y N
D. High Blood Pressure medications? ........................ Y N
E. Steroids (Cortisone, Prednisone, etc.)? ................. Y N
F. Tranquilizers?......................................................... Y N
G. Insulin or Oral Anti-Diabetic drugs?........................ Y N
H. Digitalis, Inderal, Nitroglycerin or other heart drug?Y N

I. Are you taking or have you ever taken Bisphosphonates
for osteoporosis, multiple myeloma or other
cancers (Reclast, Fosamax, Actonel, Boniva,
Aredia, Zometa, Prolia) ? ......................................Y N
J. Have you ever been advised not to take a medication?
...............................................................................Y N
K. Please list any and all medications taken, including
prescription medications, diet drugs, over-the-counter
medications, herbal or holistic remedies, vitamins or
minerals:
8. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
ADVERSE REACTION TO:
A. Local Anesthesia (Novacain, etc.)? ........................Y N
B. Penicillin or other antibiotics? .................................Y N
C. Sedatives, Barbiturates?.........................................Y N
D. Aspirin or Ibuprofen? ..............................................Y N
E. Codeine or other pain killers?.................................Y N
F. Latex or Rubber products? .....................................Y N
G. Metal of any kind? ..................................................Y N
H. Chemicals or jewelry (rash or sensitivity)?..............Y N
I. Food products?.......................................................Y N
J. Other allergies or reactions? Please list ................Y N
9. Do you smoke or chew Tobacco?..................................Y N
How much per day?
10. Is there any past history of Alcohol or Chemical
Dependency or Emotional Disorder that may affect
the care we provide you?...............................................Y N
11. Have you had any serious problems associated with
any previous dental treatment?......................................Y N
12. Have you or an immediate family member had any
problem associated with intravenous anesthesia?.........Y N
13. Do you have any other disease, condition or
problem not listed above that you think the doctor
should know about?.......................................................Y N
14. Do you wish to talk to the doctor privately
about anything? .............................................................Y N
15. Have you ever had a bone density scan? .....................Y N
16. FOR WOMEN ONLY
A. Are you Pregnant, or is there any chance
you might be Pregnant?..........................................Y N
B. Are you nursing? ....................................................Y N
C. If you are using Oral Contraceptives, it is important
that you understand that antibiotics (and some other
medications) may interfere with the effectiveness of oral
contraceptives. Therefore, you will need to use
mechanical forms of birth control for one complete
cycle of birth control pills, after the course of antibiotics
or other medication is completed. Please consult with
your physician for further guidance.
I understand the importance of a truthful and complete Health History to assist my doctor in providing the best care
possible. I have had the opportunity to discuss my Health History with my doctor.
______________ _______________________________________ ________________________________________
Date Signature Signature of Person Completing Form (if other than patient)
Oral & Maxillofacial Surgery of Abilene
Ryan Q. Green, MD, DDS
Acknowledgement of Receipt of Summary of Notice of Privacy Practices
I acknowledge that I have the option to request a copy of the Summary of Oral & Maxillofacial Surgery of Abilene
Notice of Privacy Practices memo. I am also aware that a full-length copy will be made available to me upon request.
I understand that Oral & Maxillofacial Surgery of Abilene may use and disclose medical information to contact me
regarding future appointments with the Practice. This contact may be made via either electronic and/or written
communication. I am aware these methods could potentially be received and/or intercepted by others. To restrict a
method, please circle the one(s) above you would like us to use to contact you.
_______________________________________ ___________________________________________
Patient’s Name (Please Print) Patient (Or legal guardian) Signature
_______/_______/_______
Date
I understand that it is the policy of Oral & Maxillofacial Surgery of Abilene to restrict access to my Protected Health
Information. In addition to the caregiver(s) providing health services, or my insurance company(ies) for payment of
my claim, I would like the following people to have access to my Protected Health Information.
Name Date of Birth All or Restricted*
1______________________________________________________________________________________
2______________________________________________________________________________________
3______________________________________________________________________________________
*Restricted Clinical Information: If you stated “restricted” to the above, please specify what clinical information you
DO NOT wish to share with the person(s) listed: _______________________________________________________
______________________________________________________________________________________________
This authorization will remain in effect until terminated by the patient or patient’s representative(s). State
law permits both parents to have access to patient health information UNLESS we are provided a COURT
order restricting this right.
IF THE PATIENT IS UNDER THE AGE OF 18, A PARENT OR LEGAL
GUARDIAN MUST SIGN THIS ACKNOWLEDGEMENT. Thank you.
Oral & Maxillofacial Surgery of Abilene
Ryan Q. Green, MD, DDS
FINANCIAL POLICY for Dental Procedures
Your health and well being are our primary concern. We feel that we provide the highest quality of oral
and maxillofacial surgery available to our patients. Therefore, we feel it is important for our patients to
fully understand their treatment plan, the fees involved and the method of payment. In order to avoid
any misunderstanding, we wish to explain our office policy regarding payment of fees.
Dr. Green is an independent health practitioner. He is not employed or contracted by any dental
insurance company. Your insurance plan is a contract between you, your employer, and the insurance
company. You have signed a contract with your insurance company, and therefore any benefits to
which you are entitled will be settled between the company and you. It is your responsibility to know
your coverage and benefits.
Our office policy requires that payment be made at the time services are rendered for all dental
procedures. All office visits must be paid in full at the time of service regardless of insurance. As a
courtesy, we will help you file your claim. With some insurance claims having to go medical and dental
we ask that you please be understanding through the process. For your convenience we accept cash,
money orders, and credit card payment (MasterCard, Visa, and Discover). We do not accept personal
checks. CareCredit is available to all patients needing a financing option. We do not offer in-house
payment plans.
Signature __________________________________________________ Date _____________________
I have read and understand the financial policy as stated above. I
agree to meet my financial obligation in accordance with this policy.
Should I have any questions I will contact the Insurance Specialist
responsible for my account at (325) 232-8939.
Signature __________________________________________________
Date _________________
Oral & Maxillofacial Surgery of Abilene
Ryan Q. Green, MD, DDS
INSURANCE POLICY
Our office is an out of network provider. Depending on your insurance company, we may be able to
figure costs and file the claim on your behalf. This is a courtesy to our patients to help minimize financial
burden when possible.
If we are able to file your insurance, please read the below guidelines. Our goal is to make the process
transparent and easy to understand.
1. Please make sure you present your dental insurance card, not your medical insurance card.
2. If you do not have a card for your dental insurance, please provide us with Group number, ID
number, filing address, claim phone number.
We will need the following information in order to file your insurance. We cannot file your insurance
without all of this information and without the correct information.
��� The patient legal name (as it appears on legal documents, such as your driver’s license)
��� Patient birthdate – please double check for accuracy
��� Patient social security number – please double check for accuracy
��� Subscriber legal name (exactly as it appears on insurance card). The subscriber is the main person
in your family who the insurance policy goes through.
��� Subscriber birthdate – please double check for accuracy
��� Subscriber social security number – please double check for accuracy
��� Subscriber address – this is the address that the insurance company will have on file
��� If the policy is through an employer, we will need the name of the employer that is listed on the
card and the group number.
If any of the above information is presented incorrectly, your insurance company will mark the claim as
“unprocessed”. This means if you call your insurance company, they will have no record of the claim
because the information was not correct. This is why we must receive accurate information.
If all of the information given is correct, it can take up to 12 weeks for our office to receive payment. If
the insurance company requests additional procedure information from our office, it could take up to 20
weeks to receive payment.
If your policy requires the claim to be sent to medical insurance first, it could take up to a year for us to
receive payment.
Please remember the most important factor of this process is communication. Our office is out of
network provider and we file and figure insurance as a courtesy to our patients. Thank you.
Patient / Guardian Signature Date
Oral & Maxillofacial Surgery of Abilene
Ryan Q. Green, MD, DDS
Pain Medication Policy
In order to be more efficient in addressing your pain, please be advised that pain medication refills will
be handled ONLY during our business hours.
Business hours: Monday – Thursday 8 a.m. to 4:00 p.m., Friday 8 a.m. to 12:00 p.m. We are closed on
major holidays.
Medication refills will be handled in this manner:
��� Request your refill by calling your pharmacy. They will fax us the request. Our office fax
number is (325) 232-8943. Please do not leave a voicemail at our office as it will only delay your
refill.
��� If the refill request is made on a business day, it will typically be refilled that same day.
��� If you are requesting a refill on a Friday, please make sure you contact your pharmacy before
NOON, as we close early this day.
��� Medication refill requests over the weekend will be addressed on the NEXT business day.
��� Medications WILL NOT be replaced if they are lost, stolen out of your car, fell in the toilet/sink,
eaten by pets, left at a relatives, or for any other reasons. If you do not take your medication as
directed and utilize your medication before the refill date, THERE WILL BE NO REFILLS,
REGARDLESS.
Medications must be attained from ONLY ONE (1) pharmacy. Please indicate the name and location
of your pharmacy of choice for office records: ____________________________________________.
If you change pharmacies please contact our office so that we can update your records. This office
verifies patient profiles with area pharmacies. If you are receiving pain medication from another
physician, please inform Dr. Green.
As always, should you have any questions please do not hesitate to call our office at 325-232-8939.
Patient signature: ______________________________________ Date: _____________
Dear Patient,
Welcome to APICHA and to our PRESCRIPTION PATHFINDER PROGRAM! We are excited
about the opportunity to serve you for all of your pharmacy needs.
The staff at APICHA understands that your medical condition is complex and requires special
knowledge when collaborating with your medical provider and insurance company. We are
dedicated to providing you with the personal service necessary to ensure that you achieve the
most benefit from your therapy including:
• Access to clinically-trained personnel 24 hours a day, 7 days a week
• Coordination of prior authorization with your insurance company
• Compliance monitoring
• Free mailing of medication
• Training, education and counseling
• Refill reminders
• Enrollment in the Patient Management Program, which provides benefits such as
managing side effects, increasing compliance to drug therapies and overall
improvement of health when the patient is willing to follow directions and is compliant to
therapy.
Our business hours are:
Monday, Tuesday, Friday 9AM to 6PM,
Wednesday - Thursday 9AM to 7:30PM
Eastern Standard Time
Phone: (844)370-6202
Fax: (212) 925-7233
Address: 400 Broadway, (located on lower level),
New York, NY 10013
We look forward to providing you with the best service possible. We know you have many
options and we thank you for choosing APICHA.
Sincerely,
The APICHA Team
What to expect:
We recognize that managing a chronic disease or serious illness can feel overwhelming at
times. We are here for you. At APICHA, our staff is dedicated to working with you, your doctors
and nurses, and family and friends to achieve a fully integrated health care team. You are our
primary purpose.
You can expect:
��� Personalized patient care
Our specialty trained staff members will work with you to discuss your treatment plan,
and we will address any questions or concerns you may have.
��� Collaboration with your Doctor
We will always keep the lines of communication open between you and your doctors and
caregivers. We are here to make sure any difficulties you may be having with your
treatment are addressed immediately with your physicians.
��� Regular follow-up
Getting your medications and medical supplies quickly and efficiently is paramount. We
will be in close contact with you during your treatment, and will be your healthcare
advocate.
��� Benefits
Treatment can be costly, and we will help you navigate through the complexities of the
healthcare system to explore every option available to you. Our relationships with
insurers will help provide you with information and explanations of your drug and medical
benefits. Your quality of care is our highest mission.
��� Delivery
We offer fast and convenient delivery to your home, workplace, or the location you
prefer. A staff member will contact you five to seven days prior to your refill due date to
coordinate the medications you need, update your medical and insurance records, and
to set up and confirm a delivery date and address.
��� 24/7 Support
Our Specialty Pharmacy staff is available 24 hours a day, 7 days a week. We are always
here to answer any questions or address any concerns you may have.
��� Financial Obligation and Financial Assistance
Before your care begins, a staff member will inform you of the financial obligations you
incur that are not covered by your insurance or other third-party sources. These
obligations include but are not limited to: out-of-pocket costs such as deductibles, copays,
co-insurance, annual and lifetime co-insurance limits and changes that occur
during your enrollment period.
��� Insurance claims
Staff will submit claims to your health insurance carrier on the date your prescription is
filled. If the claim is rejected, a staff member will notify you so that we can work together
to resolve the issue.
��� Co-payments
We are required to collect all co-payments prior to shipment of your medication. Copayments
can be paid by credit card, electronic checking account debit over the phone
and by check or money order through the mail.
��� Co-pay Assistance Referral Program
We have access to financial assistance program to help with co-payments to ensure no
interruptions in your therapy. These programs include discount coupons from drug
manufacturers, co-payment vouchers, and assistance from various disease
management foundations and pharmaceutical companies.
PATIENT BILL OF RIGHTS AND RESPONSIBILITIES
APICHA recognizes that patients have inherent rights.
Patients who feel their rights have not been respected, or who have questions or concerns,
should talk to the Director of Pharmacy.
Patients and their families also have responsibilities while under the care of APICHA in order
to facilitate the provision of safe, high-quality health care for themselves and others.
The following patient rights and responsibilities shall be provided to, and expected from, patients
or legally authorized individuals.
PATIENT RIGHTS & RESPONSIBILITIES
To ensure the finest care possible, as a patient receiving our pharmacy services, you should
understand your role, rights and responsibilities involved in your plan of care.
Patient Rights
• To select those who provide you with pharmacy services
• To receive the appropriate or prescribed services in a professional manner without
discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference,
gender orientation or physical or mental handicap
• To be treated with friendliness, courtesy and respect by each and every individual
representing our pharmacy, who provided treatment or services for you and be free from
neglect or abuse, be it physical or mental
• To assist in the development and preparation of your plan of care that is designed to
satisfy, as best as possible, your current needs.
• To be provided with adequate information from which you can give your informed
consent for commencement of services, the continuation of services, the transfer of
services to another health care provider, or the termination of services
• To request and receive complete and up-to-date information relative to your condition,
treatment, alternative treatments, risk of treatment or care plans
• To receive treatment and services within the scope of your plan of care, promptly and
professionally, while being fully informed as to our pharmacy’s policies, procedures and
charges
• To request and receive data regarding treatment, services, or costs thereof, privately
and with confidentially
• To be given information as it relates to the uses and disclosure of your plan of care
• To have your plan of care remain private and confidential, except as required and
permitted by law
• To receive instructions on handling drug recall
• To confidentiality and privacy of all information contained in the client/patient record and
of Protected Health Information; PHI will only be shared with the Patient Management
Program in accordance with state and federal law
• To receive information on how to access support from consumer advocatesgroups
• To receive pharmacy health and safety information to include consumers rights and
responsibilities
• To know about philosophy and characteristics of the patient managementprogram
• To identify the program’s staff members, including the program and their job title, and to
speak with a supervisor of the staff member’s supervisor if requested
• To speak to a healthcare professional
• To receive information about the patient management program
• To receive administrative information regarding changes in or termination of the patient
management program
• To decline participation, revoke consent or dis-enroll at any point in time
• To be fully informed in advance about care/service to be provided, including the
disciplines that furnish care and the frequency of visits, as well as any modifications to
the plan of care
• To be informed, both orally and in writing, in advance of care being provided, of the
charges, including payment for care/service expected from third parties and any charges
for which the client/patient will be responsible
• To receive information about the scope of services that the organization will provideand
specific limitations on those services
• To participate in the development and periodic revision of the plan of care
• To refuse care or treatment after the consequences of refusing care or treatment are
fully presented
• To be informed of client/patient rights under state law to formulate anAdvanced
Directive, if applicable
• To have one's property and person treated with respect, consideration, and recognition
of client/patient dignity and individuality
• To be able to identify visiting personnel members through properidentification
��� To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse,
including injuries of unknown source, and misappropriation of client/patient property
��� To voice grievances/complaints regarding treatment or care, lack of respect of property
or recommend changes in policy, personnel, or care/service without restraint,
interference, coercion, discrimination, or reprisal
��� To have grievances/complaints regarding treatment or care that is (or fails to be)
furnished, or lack of respect of property investigated
��� To be advised on agency's policies and procedures regarding the disclosure of clinical
records
��� To choose a health care provider, including choosing an attending physician, if
applicable
��� To receive appropriate care without discrimination in accordance with physician orders, if
applicable
��� To be informed of any financial benefits when referred to an organization
��� To be fully informed of one's responsibilities
Patient Responsibilities
��� To provide accurate and complete information regarding your past and present medical
history
��� To agree to a schedule of services and report any cancellation of scheduled
appointments and/or treatments
��� To participate in the development and updating of a plan of care
��� To communicate whether you clearly comprehend the course of treatment and plan of
care
��� To comply with the plan of care and clinical instructions
��� To accept responsibility for your actions, if refusing treatment or not complying with, the
prescribed treatment and services
��� To respect the rights of pharmacy personnel
��� To notify your Physician and the Pharmacy with any potential side effects and/or
complications
��� To notify APICHA via telephone when medication supply is running low so refill maybe
shipped to you promptly
��� To submit any forms that are necessary to participate in the program to the extent
required by law
��� To give accurate clinical and contact information and to notify the patient management
program of changes in this information
��� To notify their treating provider of their participation in the patient management program,
if applicable
If you have questions, concerns or issues that require assistance, please call us. Complaints
will be forwarded to management and you will receive a response within 5 business days.
Additional Information
��� Adverse Effects to Medication
o If you are experiencing adverse effects to the medication please contact your
physician or APICHA staff.
��� Drug Substitution Protocols
o From time to time it is necessary to substitute generic drugs for brand name
drugs. This could occur due to your insurance company preferring the generic be
dispensed or to reduce your copay. If a substitution needs to be made a member
of the specialty pharmacy staff will contact you prior to shipping the medication to
inform you of the substitution.
��� Complaints
o Patients and caregivers have the right to voice complaints and/or
recommendations on services to APICHA. Patients and caregivers can do so
by phone, fax, writing, or email.
o New York State Board of Pharmacy
��� Website: www.op.nysed.gov/opd/
��� Telephone: (800) 442-8106
��� Anyone may file a complaint against a pharmacy, but complaints must be
received in writing. A consumer may fill out the on line complaint form or
call the phone number above to have one mailed to you.
o ACHC Complaint Info
��� Website: http://achc.org/contact/complaint-policy-process
��� For further information, you may contact ACHC toll-free at (855) 937-2242
or 919-785-1214 and request the Complaints Department
��� Proper Disposal of Unused Medications
o For instructions on how to properly dispose of unused medications please
contact APICHA for instructions or go to the below FDA websites for information
and instructions
o Do not flush unused medications or pour them down a sink or drain.
http://www.fda.gov/forconsumers/consumerupdates/ucm101653.htm
http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuri
ngsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm
EMERGENCY & DISASTER PREPAREDNESS PLAN
APICHA has a comprehensive emergency preparedness plan in case a disaster occurs.
Disasters may include fire to our facility, chemical spills in the community, snow storms,
tornadoes and community evacuations. Our primary goal is to continue to service your
prescription care needs. When there is a threat of disaster or inclement weather in the local
area, APICHA will contact you prior when there is thread of disaster or inclement whether the
city may encounter which may affect your services.
However if there is a threat of disaster or inclement of weather in an area you reside which is
outside of the New York area it is your responsibility to contact the pharmacy prior to the
occurrence (if permissible). This process will ensure you have enough medication to sustain
you.
APICHA will utilize every resource available to continue to service you. However, there may
be circumstances where APICHA cannot meet your needs due to the scope of the disaster. In
that case, you must utilize the resources of your local rescue or medical facility. Please read
the guide below to aide you in case of an emergency or disaster:
1. The pharmacy will call you 3-5 days before any inclement weather emergencies such as
a snowstorm utilizing the weather updates as point of reference
a. If you are not in the New York area and are aware you will be experiencing
inclement weather you are responsible for calling the pharmacy 3-5 days before
the occurrence.
2. The pharmacy will send your medication via courier or UPS next day delivery during any
suspected inclement weather emergencies.
3. If the pharmacy cannot get your medication to you before an inclement weather
emergency occurrence the pharmacy will transfer your medication to a local specialty
pharmacy so you do not go without medication.
4. If a local disaster occurs and the pharmacy cannot reach you or you cannot reach the
pharmacy, please listen to your local news and rescue centers for advice on obtaining
medication. Visit your local hospital immediately if you will miss a dose.
5. The pharmacy recommends all patients leave a secondary emergency phone number.
If you have an emergency that is not environmental but personal and you need your
medication, please contact the pharmacy at your convenience and we will aideyou.
HOME SAFETY INFORMATION
Here are some helpful guidelines to help you keep a careful eye on your home and maintain
safe habits. The safe way is always the best way to do things. Shortcuts may hurt. Correct
unsafe conditions before they cause an accident. Take responsibility. Keep your home safe.
Keep emergency phone numbers handy.
Cleaning your hands
The most important step to prevent the spread of germs and infections is hand washing. Wash
your hands often. Be sure to wash your hands each time you:
• Touch any blood or body fluids
• Touch bedpans, dressings, or other soiled items
• Use the bathroom or bedpan
If you are coughing, sneezing, or blowing your nose, clean your hands often. Before you eat,
always clean your hands.
��� How you should clean your hands with soap and water
• Wet your hands and wrists with warm water
• Using soap, work up a good lather, and rub hard for 15 seconds or longer
• Rinse your hands well
• Dry your hands well
• Use a clean paper towel to turn off the water and throw the paper towel away
��� How you should clean your hands with hand sanitizers (waterless hand cleaners)
• For gel product use one application
• For foam product use a golf-ball size amount
• Apply product to the palm of your hand
• Rub your hands together and cover all surfaces of your hands and fingers until they
are dry
Medication
• If children are in the home, store medications and poisons in childproof containers
and out of reach
• All medication should be labeled clearly and left in original containers
• Do not give or take medication that were prescribed for other people
• When taking or giving medication, read the label and measure doses carefullyand
know the side effects of the medication you are taking
Mobility Items
When using mobility items to get around such as; canes, walkers, wheelchairs or crutches you
should use extra care to prevent slips and falls.
��� Use extreme care to avoid using walkers, canes or crutches on slippery or wet surfaces
��� Always put the wheelchairs or seated walkers in the lock position when standing upor
before sitting down
��� Wear shoes when using these items and try to avoid obstacles in your path as well as
soft and uneven surfaces
Slips and Falls
Slips and falls are the most common and often the most serious accidents in the home. Here
are some things you can do to prevent them in your home.
��� Arrange furniture to avoid an obstacle course
��� Secure throw rugs or remove them all together
��� Install handrails on all stairs, showers, bathtubs and toilets
��� Keep stairs clear and well lit
��� Place rubber mats or grids in showers and bath tubs
��� Use bath benches or shower chairs if you have muscle weakness, shortness of breath or
dizziness
��� Wipe up all spilled water, oil or grease immediately
��� Pick up and keep surprises out from under foot including electrical cords
��� Keep drawers and cabinets closed
��� Install good lighting to avoid searching in the dark
Lifting
If it is too big, too heavy or too awkward to move alone -GET HELP. Here are some things you
can do to prevent low back pain or injury.
��� Stand close to the load with your feet apart for good balance
��� Bend your knees and straddle the load
��� Keep your back as straight as possible while you lift and carry the load
��� Avoid twisting your body when carrying a load
��� Plan ahead - clear your way
Electrical Accidents
Watch for early warning signs; overheating, a burning smell, sparks. Unplug the appliance and
get it checked right away. Here are some things you can do to prevent electrical accidents.
��� Keep cords and electrical appliances away from water
��� Do not plug cords under rugs, through doorways or near heaters. Check cords for
damage before use
��� Extension cords must have a big enough wire for larger appliances
��� If you have a broken plug outlet or wire, get it fixed right away
��� Use a ground on 3-wire plugs to prevent shock in case of electricalfault
��� Do not overload outlets with too many plugs
��� Use three-prong adapters when necessary
Smell Gas?
��� Open windows and doors
��� Shut off appliance involved (You may be able to refer to the front of your telephone book
for instructions regarding turning off the gas to your home)
��� Don't use matches or turn on electrical switches
��� Don't use telephone - dialing may create electrical sparks
��� Don't light candles
��� Call gas company from a neighbor's home
��� If your gas company offers free annual inspections, take advantage of them
Fire
Pre-plan and practice your fire escape. Plan for at least two ways out of your home. If your fire
exit is through a window, make sure it opens easily. If you are in an apartment, know where the
exit stairs are located. Do not use the elevator in a fire emergency. You may notify the fire
department ahead of time if you have a disability or special needs. Here are some steps to
prevent fires:
��� Install smoke detectors as they are your best early warning, test frequently and change
the battery every year
��� If there is oxygen in use, place a "No Smoking" sign in plain view of all persons entering
the home
��� Throw away old newspapers, magazines and boxes
��� Empty wastebaskets and trashcans regularly
��� Do not allow ashtrays or toss matches into wastebaskets unless you know they are out
and have been wetted down first or dump into toilet.
��� Have your chimney and fireplace checked frequently
o Look for and repair cracks and loose mortar
o Keep paper, wood and rugs away from area where sparks could hit them
��� Be careful when using space heaters.
��� Follow instructions when using heating pad to avoid serious burns.
��� Check your furnace and pipes regularly
o If nearby walls or ceilings feel hot, add insulation
��� Keep a fire extinguisher in your home and know how to use it
If you have a fire or suspect fire
1. Take immediate action per plan - Escape is your top priority
2. Get help on the way - with no delay - CALL 9-1-1
3. If your fire escape is cut off, close the door and seal the cracks to hold back smoke and
signal help from the window
ACKNOWLEDGEMENT OF INFORMATIONAL WELCOME PACKET TO
APICHA’S PRESCRIPTION PATHFINDER PROGRAM
Please confirm that you have received the Welcome Packet for the APICHA PRESCRIPTION
PATHFINDER PROGRAM by signing and returning this form in the enclosed postage paid
envelope. Completed forms may be mailed to or dropped off at:
APICHA COMMUNITY HEALTH CENTER
Attn: Pharmacy
400 Broadway (2nd floor)
New York, NY 10013
I confirm that I have received the Welcome Packet for the APICHA PRESCRIPTION
PATHFINDER PROGRAM, which includes Hours of Operation, Contact Information, Patient
Bill of Rights and Responsibilities, Financial Obligation and Complaint Process.
Name (Please Print)
Signature
Billing Address
City, State, Zip
Phone #
Date
Thank you for choosing APICHA to service all of your pharmacy needs.

posted by Isaac Hobart at 12:32 PM