PATIENT UPDATE FORM. In an effort to have the most up to date information, we ask that this form be completed annually.

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1 PATIENT UPDATE FORM In an effort to have the most up to date information, we ask that this form be completed annually. DATE: CHART: Social Security Number Date of Birth NAME First, Middle, Last MAILING ADDRESS Zip Code: ADDRESS Please print clearly: HOME PHONE CELL PHONE WORK PHONE *Incorrect insurance information will result in denied payment and the patient will be responsible for the balance. Primary Insurance ID# Group Number Policy Holder Patient Relationship to Policy Holder Secondary Insurance ID# Group Number Policy Holder Patient Relationship to Policy Holder Were you referred by another physician for today s visit? NO YES, Dr. I understand payment is due at the time of service. Visa, MasterCard, Discover and debit cards are accepted. I authorize DeVore Dermatology to file my insurance(s) as a courtesy to me and understand payment for the services will be mailed directly to this office. If the insurance company requests information from me in order to process a claim, I will submit the requested information in a timely manner. If my insurance company does not pay the practice within a reasonable period, I will be responsible for payment. All balances due after insurance must be paid in 60 days unless a written arrangement has been made. As a courtesy to other patients, a 2 business day notice will be given when cancelling appointments. Failure to give proper notice may result in a $25 charge. I am aware that there may be a $10 administrative charge for phoning in prescriptions and a $25 administrative charge to complete any miscellaneous forms. Print Name* Signature Date *If you are not the patient please state your relationship Cosmetic Interests: Please circle any cosmetic interests you would like to discuss with the doctor today. Sclerotherapy (eliminates leg veins) Jane Iredale Mineral Makeup Botox (smoothes frown lines) Laser Hair Removal Laser Removal of Vascular Lesions (blood vessels) Microdermabrasion (exfoliates skin and cleanses pores) Dysport (the newest procedure for smoothing frown lines) Smoothing Nasolabial Folds (smile lines) Skin Care Products Laser Skin Rejuvenation (treats fine lines and sun damaged skin, no down time, encourages collagen growth)

2 Effective April 1, 2013, our office will request a credit card to be put on file for each patient account. We will still continue to file your insurance; however, we have had an increased problem collecting what insurance does not pay (co-pays, deductibles, percentage after insurance pays) and steadily declining insurance reimbursement. Our policy has always been payment at the time of service but circumstances now dictate that we must enforce this policy to stay in business. We take high priority in protecting your credit card information and have included a list of commonly asked questions and answers below. If you have a question that is not listed, please ask us. 1. WHY is my credit card information being collected? We will still file your insurance but it is not possible for us to know the exact amount due from you after insurance pays. It is unfortunate that the majority of the bills we send out are not returned with payment and this is after we have had delayed payment for services and provided the resources to file the insurance. Therefore, we have to secure payment on balances remaining after insurance has paid at the time of service. Insurance negotiates lower fees and each insurance plan is different so we cannot know details of each and every plan until the claim is submitted and paid. However, we can offer you the maximum dollar amount of your bill. 2. How and when will I know what amount will be charged to my credit card? You will receive a receipt for any amount paid at the time of service and your insurance company will send you an explanation of benefits stating the total amount due after they have paid. The difference in the two should be the amount reflected on your credit card statement. Depending upon your insurance company, your explanation of benefits will arrive via US Mail or you may have been given online access by your insurance company to view your explanations. At the time of service, our office staff will also be able to provide you with the maximum dollar amount of your bill. 3. How is my credit card information stored and is it safe? The software we use is PC Charge. PCCharge is a PA-DSS 1.2 (Payment Application Data Security Standards) validated PC POS solution that features many security safeguards and anti-fraud controls. Compliance with the PCI Data Security Standard (PCI DSS) is vital for all merchants who accept credit cards, online or offline. DeVore Dermatology is PCI compliant. We also have an outside IT company responsible for maintaining firewalls.

3 DeVore Dermatology, P.A. KAREN A. DEVORE, M.D. TEL: (864) FLOYD ROAD FAX: (864) SPARTANBURG, SC Dear Friends and Patients: Thank you for choosing DeVore Dermatology, P.A. for your dermatological care. Our goal is to provide quality medical care in an efficient matter. Please feel free to give us feedback on what we do well, as well as what we can improve upon. In order to assist us in this goal, please complete the enclosed forms and bring them to your scheduled appointment. Please arrive 15 minutes early and bring with you: a current picture ID insurance card(s) medicine list allergy list credit, debit or health savings card Please be familiar with what your insurance company requires. Ifyou need a referral to see a specialist, please call a day or two before your appointment to make sure we have received it from your primary care doctor. We collect all applicable copayments/coinsurance and deductibles at time of service. We accept cash, checks, Visa, MasterCard, and Discover. We now request a debit, credit or health savings card on file for all accounts. We will still con tinue to file your insurance; however, we have had an increased problem collecting what insurance does not pay (co-pays, deductibles, percentage after insurance pays). Any amount the insurance states is your responsibility will be applied to the card on file. We take high priority in protecting your credit card information. Please ask us ifyou have questions. If in the event you are unable to keep your appointment, we kindly ask that you give a 2 business day notice so thatwe may pass on your appointment slotto someone elsewho needs it. There is a $25 charge for last minute cancellations or no shows. Prescription requests will only be considered during normal business hours - not after hours or on weekends or holidays, so please plan ahead. It is in your best interest that we have your medicalrecord with a list of yourcurrent medications and allergies when refilling medications. There is a $10.00 charge for refilling prescriptions without an appointment. Thank you again for yourpatience andtrust. It is my pleasure to care for you andyour family. God Bless You, Karen A. DeVore, M.D. and staff

4 How To Find Us From Mary Black Hospital: Once on Skylyn Drive, Mary BlackHospitalshould be on your left. At the first traffic light after the hospital, make a left. Tliis is Floyd Road. Ouroffice is 1/4 mile on the left. From Gaffney, Gastonia, Charlotte: Merge onto 1-85 South. From Greenville: Merge onto I-85 North Take the US-221 exit, Exit #78 Take the US-221 exit, Exit #78 Turn left onto US-221/Chesnee Hwy. Go approximately 1 1/2 miles Go approximately 11/2 miles From 1-26 East: Take 1-26 East to 1-85 North Merge onto 1-85 North via Exit #18B toward Charlotte. Take the US-221 exit, Exit #78 Go approximately 11/2 miles [ Map: From 1-26 West: Take 1-26 West to 1-85 North Merge onto 1-85 North via Exit #18B toward Charlotte. Take the US-221 exit, Exit #78 Go approximately 1 1/2 miles - LIBERTY METHODIST CHURCH CO is MARY BLACK HOSffTAL it SKYLYN DRIVE SPARTANBURG DAY SCHOOL PRESBYTERIAN CHURCH EAST MAIN STREET TRAFFIC UOHT DeVore Dermatology, P.A. 490 Floyd Road Spartanburg

5 I. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of the Notice of Privacy Practices. The notice describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the Notice may be changed at any time. I may obtain a revised copy of the Notice by calling or by requesting one at the office. Date Signature of Patient/Guardian Representative* *If not the patient, please print your name and relationship to the patient: DISCLOSURE TO OTHER PERSONS REGARDING YOUR HEALTH INFORMATION (Please be aware that you may change this information at any time by requesting to complete a new form.) This practice may disclose personal health information about you to your referring doctor, family doctor, family, close personal friends or any person that you identify, as long as the information disclosed to those individuals is relevant to their involvement in your care or the payment for your care. This practice may also notify a family member or another person who is responsible for your care of your location and general health condition. I do not object to my personal health information being disclosed to a doctor, family member, friend or other individual involved in my care. Persons I authorize for disclosure: (List specific names) I object to my personal health information being disclosed to anyone other than myself. II. LAB SERVICES In the event that you have lab work done in this office, you may receive a bill for those services from another vendor. A.) Pathology specimens will be sent to Celligent Diagnostics B.) Blood work will be sent to Lab Corp C.) I will be responsible for any amount insurance does not cover Patient or Guardian Signature Date Read carefully before completing: If for insurance purposes pathology specimens or blood work need to be sent elsewhere please indicate where to send them below and notify the nurse at the time of the procedure. If at anytime this information changes, it is the patients responsibility to notify appropriate staff: Pathology Blood work Patient Signature III. COSMETIC INTEREST Please circle any cosmetic interests you would like to discuss with the doctor today. IV. How did you hear about us? Physician Friend/Family Sclerotherapy (eliminates leg veins) Internet Yellow Pages Smoothing Nasolabial Folds (smile lines) Insurance Company Laser Hair Removal Seminar Other: Laser Removal of Vascular Lesions (blood vessels) Microdermabrasion (exfoliates skin and cleanses pores) Jane Iredale Mineral Makeup Skin Care Products Botox or Dysport (smoothes frown lines) Laser Skin Rejuvenation (treats fine lines and sun damaged skin, no down time, encourages collagen growth)