Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.

Transcription

1 Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made. Name: Jr. Sr. Last First Middle Prefer to be called: Married Single Date of Birth / / Patient s Social Security Number - - Sex: Male Female Mailing Address: City State Zip Physical Address: City State Zip Address: Home Phone: Work: Cell: Employer Name: Address: Emergency Contact: Phone: Relationship: Insurance Carrier: Secondary Carrier: Policy Holder (Guarantor) if other than patient: Relationship: Guarantor s D.O.B. / / Guarantor s SSN: - - Prescription Drug Plan: Insured Responsible Party if Patient is a Minor: Relationship: D.O.B. / / Legal Guardian or Custodian of Minor: Relationship: Primary Care Physician: How did you hear about us? Do we have your permission to: Leave a message on your answering machine at home or cell phone? Yes No Discuss your medical condition with another member of your household? Yes No If yes, whom: Relationship: In order to establish optimal relations with our patients and avoid misunderstandings regarding our payment policies, our staff is trained to inform you of the financial policies of this office. Applicable copayments and deductibles will be collected. PAYMENT IS EXPECTED FROM YOU, AT THE TIME OF SERVICE, FOR YOUR PART OF THE CHARGES, unless you are in a prepaid plan in which we participate. We accept payment in the form of cash, check, Visa, MasterCard, and Discover. Your signature below indicates that you understand and accept the above policy. Further more; your signature authorizes the doctor to release such medical information necessary to process you insurance claims (if any). You herein authorize payment of medical benefits to the Doctor when an assigned claim is filed. Signature of Patient or Legal Guardian Date Reviewed By:

2 Medical History Patient Name: Date: Reason for today s visit: Would you like a full body exam today? Yes No Are you allergic to any medications? Yes No If yes, please list: List all medications you are currently taking: Preferred Pharmacy: Location: *Are you pregnant? b Yes b No If yes, Due Date: Do you have now, or have you ever had diseases or conditions of: Asthma Y N Stomach Y N High Blood Pressure Y N Hepatitis Y N Heart Attack Y N Glaucoma Y N Irregular Heart Beat Y N Arthritis Y N Pace Maker Y N Seizures Y N Diabetes Y N Artificial Joints Y N Thyroid Y N HIV (AIDS) Y N Kidney Y N Bleeding Y N High Cholesterol Y N Breast Cancer Y N Skin: When you are exposed to sun do you: Tan only Tan and burn Burn Have you ever had skin cancer? Yes No Has anyone in your family had skin cancer? Yes No If yes, who? Do you have a history of any skin diseases? Yes No If yes, please list: Do you smoke? Yes No If yes, how much? How often? Do you use IV drugs? Yes No If yes, what? How much? How often? Do you drink alcohol? Yes No If yes, how many drinks? How often? List any other disease or condition we should know about: List any surgical procedures you have had in the last 6 months: What is your occupation? What are your hobbies? Family History: If any blood relative has any condition listed below, check and specify which relative. No Relevant Family History High Blood Pressure Unknown Adopted High Cholesterol Diabetes Thyroid Disease Heart Disease

3 POLICY AGREEMENT FORM NO SHOW POLICY Due to the increasing demands for health care services we find it necessary to implement the following changes for scheduled office visits and surgical procedures. 1. We kindly request 24 hours notice for all cancellations or rescheduling of office visits or surgery appointments. This will allow for another patient to fill your appointment slot and limit delays in patient care. 2. A $25.00 charge may be applied to your account for not cancelling or rescheduling 24 hours prior to your schedule office visit. 3. A charge not exceeding 50% of your planned surgery may be applied to your account for not cancelling or rescheduling 24 hours prior to your scheduled surgery. These charges will be your personal responsibility and not cover by insurance. MEANINGFUL USE Northshore Dermatology is a participant in Meaningful Use program which is the use of certified Electronic Health Record (EHR) technology to achieve health and efficiency goals. In order to be compliant with the standards, we are required to collect specific data from our patients. Please answer the few questions below. Race: Caucasian Asian African American Pacific Islander Hispanic or Latino American Indian Ethnicity: Not Hispanic or Latino Hispanic or Latino Other Preferred Language: English Spanish Other ACKNOWLEDGMENT OF PRIVACY POLICY I,, (Print Name) have been given a copy of the Notice of Privacy Practice of Eric N. Tabor, M.D. APMC. Your signature on this form confirms your understanding of these policy s and your agreement to comply with the above stated terms. Signature: Date: Thank you for your understanding and helping us to provide exceptional dermatologic health care.

4 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient Identification Printed Name: Date of Birth: Address: Social Security # Telephone No.: Authority to Release Protected Health Information - I hereby authorize ERIC N. TABOR, M.D., A Professional Medical Corporation to release the information identified in this authorization from the medical records of (Patient s Name) and provide such information to. Authority to Release Protected Health Information I hereby authorize to release the information identified in this authorization from the medical records of (Patient s Name) and provide such information to Eric N. Tabor, M.D. at 2780 Gause Blvd., Slidell, LA 70461, Telephone No. (985) , Fax # (866) Information to be Released Covering the Periods of Health Care From (date) to q Complete Health Record q Diagnosis & Treatment Codes q Progress Notes q Partial Health Record to Include: q Consultation Reports q Complete Billing Record q History and Physical Exam q X-ray Reports q Itemized Bill q Laboratory Test Results q X-ray Films/Images q Other (specify) q Photographs & Videotapes q Discharge Summary Purpose of the Requested Disclosure of Protected Health Information - I am authorizing the release of my Protected Health Information for the following purposes (e.g. a purpose may be at the request of the individual ):. Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release - I understand if my medical or billing record contains information in reference to drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, hepatitis B or C testing, and/or other sensitive information, I agree to its release. Check One: Yes No I understand if my medical or billing record contains information in reference to HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) testing and/or treatment, I agree to its release. Check One: Yes No Expiration Date -Unless revoked, this authorization will expire on the following date, or after the following time period or event: At the end of the research study. Right to Revoke Authorization - Except to the extent that action has already been taken in reliance on this authorization, this authorization may be revoked at any time by submitting a written notice to ERIC N. TABOR, M.D. A Professional Medical Corporation, 2780 Gause Blvd., Slidell, Louisiana Re-disclosure - I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act of Signature of Patient or Personal Representative Who May Request Disclosure - I understand that I do not have to sign this authorization, and my treatment or payment for services will not be denied if I do not sign this form. However, if health care services are being provided to me for the purpose of providing information to a third-party (e.g. fitness-for-work test), I understand that services may be denied if I do not authorize the release of information related to such health care services to the third-party. I can inspect or copy the protected health information to be used or disclosed. I hereby release and discharge ERIC N. TABOR, M.D., A Professional Medical Corporation, its employees, agents and owners of any liability and the undersigned will hold them harmless for complying with this authorization. Sure Script: Patient consent to view sure scripts all-doctor drug history. Signature: Date: Description of Relationship if not patient:

5 Cosmetic Interest Questionnaire Patient Name: Date: Address: City State Zip Phone #: Please check preferred contact: qphone q qmail Health issues and procedures or products of interest to you (please check all that apply). q BOTOX Cosmetic q Skin Care Products q Lip Enhancement q Laser Skin Rejuvenation q Lengthen/Thickness of Eyelashes q Microdermabrasion q Acne Scars q Chemical Peels (BOH,TCA,Glycolic) q Uneven Skin Tone q Skin Tightening q Cool Sculpting/Fat Reduction q Juvederm/Voluma -Fillers q Laser Resurfacing q Birthmarks q Age Spots q Dry/Oily/Combination Skin q Fine Line and Wrinkles q Eye Treatments q Laser Hair Removal q Spider Vein Treatments q Leg Veins q Other, please specify Would you like to discuss any cosmetic procedures with Dr. Tabor today? Yes No Please answer the following questions on a scale of 1 to 5 by circling the appropriate number. When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age. Younger Than True Age Older Than When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles. Not Concerned Somewhat Concerned Very Concerned Thank You!