Allergen Testing Referral Form printable pdf download

Allergen Testing Referral Form

Date: ____/____/_______

Dr. ____________________________,

Our records indicate that your patient, _____________________________________, has not

been tested for common respiratory inhalant allergens that may be contributing to their asthma

symptoms. The NIH Guidelines for the Management of Asthma recommends the assessment of

allergic triggers in all patients diagnosed with persistent asthma. Specifically, all patients

prescribed a daily medication to control their symptoms should be tested to reliably determine

their sensitivity to inhaled allergens. In vitro IgE testing has recently been approved to be

paid for by several Texas Managed Medicaid Plans (listed below).

Typically, Asthma Action Plans for adults and children include a checklist of asthma triggers,

both allergic and non-allergic. However, without information gained from IgE testing,

documentation of a patient's specific allergic triggers is limited to qualitative information

provided by the patient. Elevated specific IgE test results, when consistent with patient history,

symptoms, and clinical exam, support the diagnosis of allergy and allow for more effective

management of the allergy, including pharmacotherapy.

If you have not done so, you may order the IgE testing from the lab corresponding to the patient's

Texas Managed Medicaid Plan as indicated below. If you have any questions or concerns, please

contact me using the contact information provided below. Thank you for your commitment to

improve the care of your patient with persistent asthma.

Sincerely,

_________________________________________

Phone: _______________________________

Fax: ______________________________

Email: _______________________________________

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Allergen Testing Referral Form