NEW PATIENT FORMS OUR LOCATIONS

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1 NEW PATIENT FORMS Welcome to Evans Dermatology Partners. These New Patient Forms will help us get to know you a bit better. You may complete them by hand, or fill them in electronically, and bring them to your first appointment. Please remember to bring: Parent or guardian must accompany all patients under 18 years old Caretaker must accompany incapacitated patients OUR LOCATIONS South Lamar 3508 South Lamar, Ste. 300 Austin, TX Brodie Lane 9701 Brodie Lane, Ste. 106 Austin, TX Kyle Parkway Interstate 35, Ste. 200 Kyle, TX Just north of the intersection of S. Lamar and 290. In the same building with Red s Back Porch and BB&T bank. Near Brodie & Slaughter, just north of the Randall s Shopping Plaza and Goodwill. Exit 215 Kyle Parkway. On the northbound service road, in front of Hays Surgery Center and next to Discount Tire. (512) Fax: (512) evans-dermatology.com

2 NEW PATIENT REGISTRATION FORM PATIENT S PERSONAL INFORMATION Social Security # Date of Birth / / Marital Status Race White Other Decline Ethnicity Hispanic Other Decline Preferred Language (if other than English) Address Sex M F Phone Numbers Home Cell Work Address PERSON RESPONSIBLE FOR BILL Name Preferred Means of Communication Home Cell Work Relationship to Patient Parent Other Date of Birth / / Phone Address Insurance Co. Policyholder s Name Guarantor Address Street PRIMARY MEDICAL INSURANCE Employer Relationship to Patient Parent Other Social Security # Date of Birth / / SECONDARY MEDICAL INSURANCE Insurance Co. Policyholder s Name Employer Relationship to Patient Parent Other Social Security # Date of Birth / / PRIMARY CARE PHYSICIAN Full name Did this doctor refer you to us? PREFERRED PHARMACY Name Address EMERGENCY CONTACT Relationship Parent Name to Patient Other Phone

3 DERMATOLOGY ASSOCIATES Financial Policy This Document contains important information regarding our financial policies. Please carefully review the policies and sign in order to be seen by one of our providers. Payment for Services Payment is required for all services at the time the services are rendered. For in-network services this includes any co-pay, co-insurance and/or deductible. Insurance coverage is not a guarantee of payment by your insurance company. You are financially responsible for all services rendered on your behalf or on behalf of your dependents. If your insurance company fails to respond or does not pay promptly, we will forward the balance to you for payment. Out-of-Network Services and Private Pay Patients If we are not in network with your insurance, or if you are not insured, payment will be required at the time of service. It is your responsibility to verify with your insurance plan if we are a contracted provider. Cosmetic Services Services that are not medically necessary cannot be submitted to insurance. You will be asked to pay at time of service for any cosmetic procedures. Dermatopathology When a biopsy or surgical procedure is performed, the specimen(s) will be sent to a specialist physician (dermatopathologist) for microscopic examination. As a result, there will be two separate charges one for the in-office procedure and another for the diagnosis of the specimen. Laboratory Services Some insurance companies require preferred laboratories for bloodwork. It is your responsibility to know the preferred laboratories under your insurance policy. Please let us know at each visit if a specific lab is required. Delinquent Accounts and NSF Checks We refer delinquent accounts to an outside collection agency. If your account is referred to a collection agency, a fee of up to 30% of your balance due, plus an administrative service fee of $25, will be assessed to your account. Your phone information will be used for collection efforts, including automated dialing systems (for which you may opt out at a later date).there is a $25 charge for checks returned for insufficient funds, and payment of the check and fee will be due immediately. Financial Hardship If you are facing financial hardship, please ask to speak to a patient account representative so that we may work with you. We want to help you understand the cost of your care. If you have any questions or concerns about this financial policy, please ask a staff member and we will be happy help. Cancellation Policy If the patient cannot adhere to a scheduled appointment, it is the patient s responsibility to call the office to cancel at least 24 hours prior to the scheduled appointment. We reserve the right to charge the patient a $50 fee if that patients does not cancel the appointment 24 hours in advance. Additionally, we reserve the right to reschedule appointments to which the patient is more than 30 minutes late. I have read this financial policy and I agree to meet my financial obligation related to the care that I, or my dependents, receive. Print Patient Name Date of Birth Signature Patient or Legal Guardian/Responsible Party Date REV 11/16

4 PERSONAL HEALTH HISTORY PATIENT NAME DATE OF BIRTH / / TODAY S DATE / / REASON FOR VISIT MEDICAL HISTORY Allergies to medications Name of the drug NONE Reaction you had Current medications, incl. over-the-counter drugs, vitamins & supplements NONE Have you ever had any of the following? Other Cancer Diabetes Type I Type II Heart Disease Hepatitis C Unknown High Cholesterol Liver Disease Lung Disease Psoriasis Melanoma Other Unknown

5 PATIENT NAME DATE OF BIRTH / / Any other medical problems that other doctors have diagnosed? Surgeries NONE FAMILY HISTORY Has anyone in your family ever had: Melanoma Other Unknown Psoriasis Other skin Description HEALTH HABITS What is your occupation? User FEMALE PATIENTS ONLY COSMETIC CONCERNS (optional) MESSAGES REGARDING LAB/PATHOLOGY RESULTS

6 AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION (Optional) Patient Name Date of Birth / / You do not need to list your other physicians. Name Relationship Phone / / Patient/Guardian Signature Date

7 AUTO BILL PAY (Optional) Patient Name Date of Birth / / insurance as patient responsibility. Please automatically charge: Card Holder Name: Credit Card Number: Expiration Date: Security Code: Billing Address: Signature: Date / /