HTML Preview Clinic Patient Letterhead page number 1.
4202 East Fowler Avenue, SHS100
Tampa Florida 33620-6750
Phone: (813) 974-2331 Fax: (813) 974-5888
SHS-Nursing-"Antigen Clinic Pot. Patient”12/09; rev 6/2017
To: Antigen (Allergy) Clinic Potential Patient
From: Dee Belangia, Sr. RN, Antigen Clinic Supervisor
Michelle Sykes, Sr. LPN, Antigen Clinic Nurse
Student Health Services at the University of South Florida welcomes all new antigen patients to our clinic. Student
Health Services staff will not administer your initial injection(s). You must receive initial injection(s) from your
prescribing Allergist. If greater than six (6) months since your last injection(s) you must present to your Allergist
office to be restarted. Supportive documentation of restart of injections will be required.
Complete WRITTEN instructions must be submitted by the prescribing physician on office letterhead before request
for receipt of antigen therapy can be submitted for review by SHS Medical Director and/or designee. The
review/approval process will be between 5-7 business days for completion. No injections are administered until
approval obtained.
Instructions and information must be explained in detail before antigen injections can be administered. It is the
STUDENT'S RESPONSIBILITY to provide these instructions and their antigen extract vial(s) from his/her private
physician.
These instructions must include:
1. Patient's name
2. Dosage schedule
3. Frequency of injections
4. Contents of each vial
5. Concentration of each vial
6. Concentration dose amount & date of last injection(s)
7. Dose adjustment for missed/late injections
8. Dose adjustment for local reactions
9. Minimal number of days between injections
10. Epi-Pen device (current). Pt. will be instructed to obtain script from Allergist to replace device prior to exp. date.
11. Expiration date of vial(s) – (month/day/year)
12. ICD-9 Dx Code for insurance billing
Antigen extract vial(s) are not to be mailed to our facility. If mailed, the allergy materials should be mailed to you,
who will then hand-carry it to Student Health Services.
Updated instructions are also required which outline the same information for all new supplies of antigen extract.
This applies even if the new vial(s) has the same contents as the previous vial(s). A copy of the injection record will
be given when ordering new extract.
Should any problems develop while receiving your antigen injections, you will be referred back to your private
physician for evaluation.
Please call Student Health Services to arrange a screening appointment when you have obtained all the above
information from your physician. Bring your vial(s), instructions, and student ID card for your screening
appointment. Your physician's instructions and vial(s) information will be reviewed by an antigen nurse. During the
screening process, the nurse will also explain the Antigen Clinic's policies and procedures. The fee for a screening
appointment is $24.00. You will not be given any injection(s) on the day of your screening appointment.
The current fee for receiving antigen injections is $15.00 for a single injection. Multiple injections are $20.00.
Prices are subject to change. Antigen extracts are not combined for injection administration.
In the event of an anaphylactic reaction, there will be additional charges for any emergency medications
administered.
We look forward to assisting you with your antigen injections. Please contact the Antigen Clinic Services
Coordinator if you have any questions or need additional information.