Past Medical & Surgical History (Please list any diseases or conditions that you have now or have ever had) (DO NOT LEAVE BLANK)

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Cameron Wilkinson
6 years ago
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1 Date of visit: Name: SS#: - - DOB: / / Race: Ethnicity: Language: Reason for your visit today: Referring physician: PCP: Best number to reach you for your test results: May we leave a message? Yes No Male Female Age: Height: Weight: If female, are you pregnant or think you could be pregnant? Yes No Breastfeeding?: Yes No Preferred pharmacy: Pharmacy phone: Past Medical & Surgical History (Please list any diseases or conditions that you have now or have ever had) (DO NOT LEAVE BLANK) Have you ever had skin cancer? Yes No Do you take antibiotics before surgery due to artificial heart valves or artificial joints? Yes No Do you have an allergy to latex, lidocaine or iodine? Yes No Do you develop keloids after surgery? Yes No Family History: If any blood relative has any condition listed below, check and specify which blood relative [Ex: Mother/Father/Sister/Brother/Child/Uncle/Aunt/Grandparent] Autoimmune Disease High Blood Pressure Melanoma Colon Cancer High Cholesterol Obesity Diabetes Liver Disease Skin cancer Glaucoma Lung Disease Thyroid Disease Premature Coronary Dis. Medications (Please list all of your current medications, including vitamins, supplements and herbal medications) Allergies None Social History Do you drink alcohol? Yes No Do you smoke? Yes/Packs per day? No Quit/How long ago What is your occupation? What are your hobbies?

2 New patient information form Date: Patient Name: Male Female Birthdate: Social Security #: Address: Address: Apt: City: State: Zip: Home Phone: Cell Phone: Check appropriate box: Minor Single Married Divorced Widowed Separated Whom may we thank for referring you? Emergency Contact: Relationship: Phone: Primary Insurance Information Guarantor of policy: Relationship to patient: Birthdate: Insurance Company: Id#: Secondary Insurance Information Guarantor of policy: Relationship to patient: Birthdate: Insurance Company: ID#:

3 Communication/Privacy Consent Form Patient Name DOB Due to the HIPPA regulations and the number of patients who have voic s and/or answering machines on their telephones, we need some information about how to better communicate with you. Occasionally it is necessary that we call patients regarding a surgery or appointment time change, test results, and/or billing matters. Please answer the following questions so that we can contact you in the most efficient way possible. May we leave a message on your answering machine at your home? YES NO N/A May we leave a message on your cell phone? YES NO N/A May we leave a message on your spouse s cell phone? YES NO N/A May we call you at work? YES NO N/A May we leave a message on your voice mail at work? YES NO N/A If we call you at home, and you are unavailable, may we leave a message with another person? YES NO N/A If you are available by work or cell phone, list the numbers below: Work # Cell # Please list the person(s) (including spouse, if applicable) that you authorize us to release information to. Name Relationship Phone Number(s) Name Relationship Phone Number(s) Name Relationship Phone Number(s) Name Relationship Phone Number(s) Patient /Guardian Signature Date

4 Receipt of Notice of Privacy Practices Written Acknowledgement Form Comprehensive Dermatology & Facial Plastic Surgery I am a patient of Comprehensive Dermatology & Facial Plastic Surgery. I hereby acknowledge receipt of Comprehensive Dermatology & Facial Plastic Surgery's Notice of Privacy Practices. Name [please print]: Signature: _ Date: OR I am a parent or legal guardian of [patient name]. I hereby acknowledge receipt of Comprehensive Dermatology & Facial Plastic Surgery's Notice of Privacy Practices with respect to the patient. Name [please print]: Relationship to Patient: Parent Legal Guardian Signature: _ Date:

5 Practice & Payment Policies: Responsible Party We try to provide you, the patient, with the most appropriate patient centered care at a reasonable cost. To continue to make this possible we need your help and participation. Here is how: 1. If you are in doubt about whether we accept your primary or secondary coverage, please work with our staff to confirm coverage in advance. There are a multitude of insurance plans that sound alike but may be different and we may not have contracted with them to provide covered services. 2. If you have a change in insurance coverage status or coverage information, please inform the front desk when you schedule your appointment or on check-in at day of service. Accurate insurance information is critical to the timely determination of covered services. 3. We collect co-payments, prior account balances, and, if necessary, any large deductibles, at time of service. Please be aware of your plan coverage provisions and your payment status. We would prefer not to, but we reserve the right to not provide you with service should you be unwilling to make these payments in advance of services. 4. If your particular insurance plan requires it, you need to be aware of, and provide us with either: a. Prior written referral from your primary care physician or specialist, or b. Pre-authorization for treatment from your insurance company 5. If you are paying in cash or we have not contracted with your insurance plan, we require payment in full at the time of service. We accept cash, checks, Visa, Mastercard and Care Credit. Payment plans can only be arranged in advance. Any checks returned for insufficient funds will be charged a $25 handling fee, in addition to any bank service fees. 6. We are happy to provide you with an estimated or final itemized bill. If you are paying in cash and/or submitting separately to your insurance company, please ask us for a preliminary estimate before we provide you with any services and a final itemized bill when we have completed those services. 7. Because insurance plans vary considerably, we cannot predict or guarantee what part of our services will or will not be covered. We forward requests for payment coverage of billed services to our contracted insurance companies on a timely basis and only bill you directly for any non-covered amounts following your insurance company s determination of benefits. 8. Since we have provided a service we expect to be paid for that service. Our policy is that your remaining unpaid balances for services provided are due within 25 days of our billing date. If, for some reason, you are unable to make this payment on a timely basis, please contact our billing and collections department. We prefer not to forward your account to a collection agency for servicing, but that may be necessary after your account is 90 days past due and you have not made prior arrangements with our billing and collections department. Insurance plans are third party payers and have only contracted with us to provide payment for covered services. The contract for the actual services provided is between you and our practice and you are ultimately responsible for payment. Insurance plans can, at times, be challenging to understand. When in doubt, let us help you resolve any issues of covered services in advance, so you can focus on what you are here for: the best medical treatment we can provide. If you have any questions, please do not hesitate to ask any member of the staff. Please acknowledge by signing below: Responsible Party Signature: Please Print Your Name: Relationship to patient:

SOUTHWEST DERMATOLOGY CENTER Martin J. Safko, MD PATIENT INFORMATION

SOUTHWEST DERMATOLOGY CENTER Martin J. Safko, MD PATIENT INFORMATION PATIENT NAME SEX M F ADDRESS Martin J. Safko, MD PATIENT INFORMATION LAST FIRST MI STREET UNIT # CITY STATE ZIP SOCIAL SEC. NO. / / CHECK ONE MARRIED SINGLE DIVORCED WIDOWED HOME PHONE ( ) CELL NO. ( )