BIRCH BAY DERMATOLOGY

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Brendan Montgomery
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1 BIRCH BAY DERMATOLOGY PATIENT INFORMATION Photo ID (State or Federal) Please provide this to the receptionist PATIENT REGISTRATION FORM By providing your contact information below, you are granting permission to be contacted via these communications methods regarding your care. Patient Name: Address: First Middle Last Number/Street City/State Zip Address: Cell; including text message: Employer: Work: Date of Birth: Sex: Male Female Social Security #: Marital Status: Partner's Name: Yes, you may discuss billing / medical details with this individual RESPONSIBLE PARTY (complete ONLY if the party responsible for billing is NOT the patient named above) Name: Address: First Middle Last Number/Street City/State Zip Cell: Work: Ext. Date of Birth: Sex: Male Female Social Security #: Relationship: Why are you the responsible party: INSURANCE INFORMATION Insurance Cards MUST Be Presented To The Receptionist This serves as notice that ALL of the requested information listed below IS REQUIRED to submit a claim to your insurance company whether or not your insurance card is present. Failure to complete the requested information will result in the total balance being patient responsibility and payment will be due at the time of service. Please present your insurance card(s) to the receptionist upon completion of this form. PRIMARY INSURANCE INFO (required) SECONDARY INSURANCE INFO (required) Insurance Name: Insurance Name:.Policy/Member #: Policy/Member #: Group/Plan #: Group/Plan #: Subscriber Name: Subscriber Name: Subscriber Gender: M F DOB: Subscriber Gender: M F DOB: Sub. Relationship: Self Spouse Child Other Sub. Relationship: Self Spouse Child Other Copay Amount: Copay Amount: eferral Required: Yes No Referral Required: Yes No Page 1 of 5

2 BIRCH BAY DERMATOLOGY PATIENT REGISTRATION FORM EMERGENCY CONTACT INFORMATION Please provide a contact that is NOT living with you Name: Relationship: COMMUNICATIONS: Do we have permission to: Leave a message on your voic regarding your medical condition/billing? Preferred contact method: Yes Cell: No It is okay to discuss my medical condition/billing with: BILLING AND PAYMENT POLICY We are committed to providing you with the best possible care. If you have medical insurance we are eager to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. 1. CONTRACTED INSURANCE: All contracted insurance companies are billed directly as a courtesy. Any remaining balance for non- covered benefits, deductibles, and co- insurance are your responsibility. Payment for any patient responsibility is due upon receipt of your monthly statement. 2. BENEFITS/COVERAGE: It is your responsibility to understand your insurance benefits. Insurance coverage is not a guarantee of payment for services provided including, preventive, routine screening, vaccinations, or procedures considered not medically necessary and/or cosmetic in nature. 3. REFERRALS/AUTHORIZATIONS: It is your responsibility to obtain referrals from your PCP. Please notify the receptionist if your plan requires a referral or pre- authorization. If a referral is not in place your appointment may be rescheduled. 4. CO- PAYS: All co- pays are expected at the time the service is rendered. It is the patient s responsibility to notify the receptionist upon arrival that a co- pay is due. A $40.00 handling fee may be added to your statement if you do not pay at the time of service. 5. NON- CONTRACTED INSURANCE: All charges are considered patient responsibility if we are not contracted with your insurance. A claim may be filled as a courtesy; however, a contractual adjustment will not apply. Payment is due upon receipt of your monthly statement. 6. RETURNED CHECKS: There will be a $25.00 charge for all returned checks. 7. NO SHOW/CANCELLATION POLICY: Our office strives to give each patient personal attention. We kindly request a 24 hour notice for medical appointment cancellations and a 48 hour notice for surgical and cosmetic appointment cancellations, otherwise the following charges may be applied: Medical appointments: $75 / Surgical or Cosmetic Filler appointments: $250 All cosmetic services require valid credit card information when booking an appointment. The information provided is true to the best of my knowledge. I authorize treatment for myself or the above individual and I understand that I am ultimately responsible for charges associated with medical services and agree to pay all bills upon receipt of the statement, unless other arrangements are made. I authorize the physician to release to my Insurance and its agents any information required to process my insurance claims. I further agree that a copy of this agreement shall be as valid as the original. I authorize my insurance company to pay the provider directly. This form must be signed by hand. Please complete the form then print and sign. Patient/Responsible Party Signature Date

3 Birch Bay Dermatology PATIENT INFORMATION SEX: Male Female RACE Current daily smoker African American Asian Caucasian Occasional smoker Native American Other Decline ETHNICITY: Former smoker Hispanic Non-Hispanic Decline NEVER SMOKER LANGUAGE: English Other: Primary care physician (PCP) Referring Provider if different from PCP Preferred Pharmacy Name Street pharmacy is located on Health History Questionnaire SMOKING STATUS Patient Name & Date of Birth PCP Phone Number City/Town of Pharmacy Conditions: Yes No Condition: Yes No Pacemaker Allergy To Topical Antibiotics Defibrillator Blood Thinners Artificial Joint(s) Within Last Two Years Pregnant/ Planning To Become Pregnant Artificial Heart Valve Allergy To Lidocaine Need to medicate Prior To Procedures Rapid Heart Beat With Epinephrine Allergy To Adhesive Stomach Upset With Oral Antibiotics Do you currently have any of the following medical conditions? Conditions: Yes No Review of Systems: Yes No Arthritis Problems with bleeding Asthma Problems with healing Atrial Fibrillation- Irregular Heart Beat Problems with scarring (hypertrophic or keloid) Bone Marrow Transplantation Immunosuppression Benign Prostatic Hypertrophy Changing mole Breast Cancer Rash Colon Cancer Abdominal pain COPD Anxiety Coronary Artery Disease Bloody stool Diabetes Bloody urine End Stage Renal Disease Chest pain GERD Cough Hearing Loss Depression Hepatitis B or C Fever or Chills History of Hepatitis Headache Hypertension Hay fever HIV/ AIDS Joint aches Hypercholesterolemia Muscle weakness Leukemia Neck stiffness Lung Cancer Night sweats Lymphoma Seizures Prostate Cancer Shortness of breath Radiation Sore throat Stroke Thyroid problems History of Tuberculosis Unintentional weight loss Tuberculosis Wheezing

4 Birch Bay Dermatology Health History Questionnaire List any surgeries that you have had Surgery Date Surgery Date Have you had any of the following skin conditions? Skin Condition YES Skin Condition YES Melanoma, location / year: Blistering Sunburns Actinic Keratosis (Pre- cancers) Abnormal Moles Basal Cell Skin Cancer Eczema or Psoriasis Squamous Cell Skin Cancer Tanning Booth Use? Do you have a family history of Melanoma? Yes No If Yes, relationship to the patient: Have you or a family member ever been diagnosed with cancer? Cancer Name/Type/Location Relationship to you List your current MEDICATIONS: List your ALLERGIES: NONE Circle if you are not taking any medications NKDA Circle if No Known Drug Allergies

5 BIRCH BAY DERMATOLOGY HIPAA PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The Practice has a Notice of Privacy Practices and the patient has the opportunity to review this Notice. The Practice reserves the right to Change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition receipt of treatment upon the execution of this Consent. This Consent was signed by: Printed Name - Patient Representative Signature Date Relationship to Patient (if other than patient) For Office Use Only Documentation of Good Faith Efforts To obtain patient's acknowledgement that they received provider's Notice of Privacy Practices The above named patient presented to the office and was provided with a copy of the Notices of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgement of his/her receipt of the notice. However, such acknowledgement was not obtained because: Patient refused to sign Patient was unable to sign because: Date: /_ / Employee Signature:

Natural Image Skin Center Registration Form

Natural Image Skin Center Registration Form New Patient Name Change Address Change Insurance Change Please present ALL Insurance cards to the receptionist. If patient is a minor, and you are not the legal