History and Physical Examination

Sample Form

The ACAAI has prepared a sample History and Physical Examination Report Form that complies with proposed, but recently postponed, regulations of the Health Care Financing Administration (HCFA).

Because of the format of the form, we have chosen to provide it in Adobe's Portable Document Format (PDF).

The HCFA was to begin enforcement of new evaluation and management (E&M) regulations in July 1998. However, in April the agency announced an indefinite postponement of enforcement.

HCFA officials said that they will continue to evaluate the proposed regulations. In the meantime, they have directed Medicare carriers to continue using both the 1994 and 1997 documentation guidelines, whichever is more advantageous to the physician.

The sample form is not copyrighted, so individual allergists may copy or modify it for use in their own practices.