Medical History Form

Size: px

Start display at page:

Download "Medical History Form"

Muriel Hall
6 years ago
Views:

1 Medical History Form Patient Name: Occupation: Why are you here today? Preferred Pharmacy: Pharmacy Phone #: Pharmacy City/Zip: Do you have a primary care physician? Yes No When was the date of your last visit? Current Weight: Height: Past Medical History: (Please circle all that apply) Anxiety Coronary Artery Disease Hypo-Thyroid Arthritis Depression Hyper-Thyroid Asthma Diabetes Leukemia Atrial Fibrillation End Stage Renal Disease Lung Cancer BPH GERD Lymphoma Bone Marrow Hearing Loss Prostate Cancer Transplantation Hepatitis Radiation Treatment Breast Cancer High Blood Pressure Seizures Colon Cancer High Cholesterol Stroke COPD HIV/AIDS Other: NONE Past Surgical History: Skin Disease History: (Please circle all that apply) Acne Dry Skin Cancer Actinic Keratosis Eczema Poison Ivy Asthma Flaking or Itchy Scalp Precancerous Moles Basal Cell Carcinoma Hay Fever/Allergies Psoriasis Blistering Sunburns Melanoma (MM) Squamous Cell Carcinoma If history of MM did you have imaging done? Yes No Other: Do you wear sunscreen? Yes, SPF No Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes, which relative(s)? No Do you have a family history of Diabetes? Yes, which relative(s)? No Do you have a personal history of any of the following: Diabetes Yes No COPD Yes No Coronary Artery Disease Yes No Heart Failure Yes No ADF

2 Medications: (Please list ALL current medications and dosage) No Meds Allergies (Please list all allergies and reactions) No Known Allergies Social History: (Please circle all that apply) Alcohol Use: None On a single occasion in the last year how often have you had 3 (females) or 4 (males) drinks? Less than 1 drink per day 1-2 drinks per day Never 3 or more drinks per day Less than monthly Monthly Weekly Daily or almost daily Cigarette Smoking: Never Smoked Quit: Former Smoker Smokes less than daily Smokes daily For current tobacco users, select the option that best describes use: 1-3 cigarettes per day up to 1 pack per day 1-2 packs per day 2 or more packs a day Immunizations: Have you received the following immunizations? Flu Vaccine Yes No Pneumonia Vaccine Yes No Pain Related to Dermatology Appointment: Are you experiencing any paid today related to your dermatology appointment? Yes No If yes, please rate the pain from 1 10 (10 being the worst) Falls: Have you had a fall within the last 12 months? Yes No If yes, how many falls? Have you gotten medical help regarding the falls? Yes No Advanced Care Plan Do you have the following: Power of Attorney (surrogate decision maker) Yes No If yes, what is the name of POA: Living Will Yes No ADF

3 PATIENT INFORMATION: LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP: HOME # ( ) CELL # ( ) PREFERRED CONTACT METHOD: HOME CELL BIRTHDATE: / / SEX: M F SOCIAL SECURITY NO: MARITAL STATUS: M S OTHER TITLE: Mr Mrs Ms Dr ETHNICITY: RACE: PREFERRED LANGUAGE: PRIMARY CARE PHYSICIAN: First Name: Last Name: Dr s #: REFERRING PHYSICIAN: First Name: Last Name: Dr s #: RESPONSIBLE PERSON IF PATIENT IS UNDER 18: RELATIONSHIP: MOM / DAD / OTHER: LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP: HOME # ( ) CELL # ( ) BIRTHDATE: / / SOCIAL SECURITY NO: PRIMARY HOLDER OF THE INSURANCE: RELATIONSHIP: SELF SPOUSE CHILD OTHER: LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP: HOME PHONE: ( ) CELL PHONE: ( ) BIRTHDATE: / / SEX: M F SOCIAL SECURITY NO: NAME OF INSURANCE COMPANY: PRIMARY HOLDER OF SECONDARY INSURANCE: RELATIONSHIP: SELF SPOUSE CHILD OTHER: LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP: HOME PHONE: ( ) WORK PHONE: ( ) BIRTHDATE: / / SEX: M F SOCIAL SECURITY NO: NAME OF INSURANCE COMPANY: AUTHORIZATION TO ASSIGN BENEFITS AND RELEASE MEDICAL INFORMATION For services rendered, I hereby assign payment from my insurance company to Arrowhead Dermatology. I shall be financially responsible to pay for any non-covered charges, medications, unpaid balances, deductible or co-insurance. Should payment come to me from my insurance company for any reason or inadvertence, I understand I am not entitled to keep any monies, but must return money owed to Arrowhead Dermatology. I further authorize release of any and all medical information necessary to help in processing my claims. I also permit a photocopy of this authorization to be used in place of the original.

4 SIGNATURE DATE ADF Arrowhead Dermatology Keith J. Haar, M.D. Lisa R. Hynes M.D. Julie Jacobs, D.O. Ryan A. Stevens, M.D. Carlos F. Rodriguez, M.D. Joan Altman, P.A.-C Rebecca L. Caudle, P.A.-C Velika Lotwala, P.A.-C Sara Royse, P.A.-C RELEASE OF INFORMATION Patient Name: DOB: Please check one of the following: I give my consent to the staff of Arrowhead Dermatology to relay any lab, or any other imperative information to: Name Relationship Phone Number Name Relationship Phone Number Answering machine at home. I do not give consent to have my test results relayed to anyone other than myself. I give my consent for any and all information to be released to my primary care physician. Dr/PA/NP., office phone#. EMERGENCY CONTACT: Name Relationship Phone Number Consent (initial) I hereby give my consent for Arrowhead Dermatology providers to examine my skin, areas of concern or deemed clinically appropriate. Signature Date ADF

5 Patient Acknowledgement of Arrowhead Dermatology HIPAA Notice Patient s or Guardian s Name: Date of Birth: Patients name: I understand that my/the patient s health information is private and confidential. I understand that Arrowhead Dermatology works hard to protect my/the patient s privacy and preserve the confidentiality of my/the patient s health information. I understand that Arrowhead Dermatology may use and disclose my/the patient s health information to provide treatment to me/the patient, to handle billing and payment, and to take care of other healthcare operations. In general, there will be no other uses and disclosures of this information unless I permit it. Arrowhead Dermatology has a detailed document called the Notice of Privacy Practices. It contains more detailed information about how they may use and disclose patient health information and I acknowledged that I have received a copy of this Notice for my own records. Arrowhead Dermatology may update the Notice of Privacy Practices. If I ask Arrowhead Dermatology will provide me with the most current Notice of Privacy Practices. My signature below indicates that I have been given a copy of a current copy of Arrowhead Dermatology s Notice of Privacy Practices. Patient or Legally authorized individual signature Date Time Relationship to patient if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)

6 ADF Financial Policy Thank you for choosing Arrowhead Dermatology (AD) as your skin care specialist. Our purpose as board certified professionals is to provide the utmost in personal and professional medical care for our patients. AD s financial policy is documented to ensure transparency in the areas of finance, payments and insurance. It is important that our communication is simple and straightforward as we partner together with our patients. Anyone within our leadership team will be happy to answer any questions you may have. Please Initial Each Item Below 1. Payment Methods: We accept only cash, American Express, Visa, MasterCard and Discover. Checks are no longer accepted at the time of service. However, if a check is mailed in for statement balances they will be accepted. Should a check be returned for any reason, AD will assess a $50 fee for bank charges and special handling. 2. Required Documents: Items we require include updated copies of our patient information packet, insurance card, driver s license or state issued ID, and a patient photo for security purposes. Some companies require Social Security Number for insurance and billing purposes. 3. Patient Payment: Co-Pay, deductibles and coinsurance are all due and payable at the time of your appointment and/or procedure. All payments are an estimate based on your contract terms. Note even with preauthorization it does not guarantee payment. Any unpaid balances will be the responsibility of the patient. AD is bound to final decisions made by your in-network insurance company. 4. Claim Submission & Assignment of Benefits: AD agrees to handle insurance claims on behalf of the patient. Patient agrees to release those funds in full to AD. AD will assist in filing appeals if payments are limited by out-of-network and/or in-network rejections/declines. 5. AD Fee Schedule: AD goes to great lengths to insure the fees charged in the office are both reasonable and follow all applicable laws. We are unable to negotiate reduced fees (copays, deductibles, etc) with your insurance carrier. 6. Contact information: It is the patient s responsibility to notify AD of any changes to insurance coverage, Insurance card, ID, residence and mailing address, and phone number. 7. Timely Payment of Outstanding funds: AD will receive an EOB (Explanation of Benefits) from the patient s insurance payor, which notifies AD of a final payment decision and outstanding balances due from patient. Insurance companies are legally permitted 30 days for processing a claim and returning payment. Should payment be left unpaid at 60 days, the outstanding funds will be deemed patient responsibility. Patient will then be notified via monthly statement and patient agrees to pay those funds in full upon receipt. 8. Collection Activity: AD is willing to discuss payment arrangements. If final payment is not made within 60 days of statement date, delinquent accounts are released to U.S. Collections West, Inc. at which time additional fees will be added to the outstanding balance. This includes a contract fee of 50% of the final bill and up to 20% APR billed monthly, along with any legal fees. 9. Financial Hardship: AD is legally bound to the terms of a patient s Insurance Contract. Within those boundaries, AD is happy to work with a patient to seek a mutually agreed upon payment arrangement. Should a hardship transpire, AD will require a patient to file a Financial Hardship Form and supply required documentation. 10. No-Show Fee: We do require a 24-hour cancellation notice and we reserve the right to assess a $50 fee for missed appointments. Should missed appointments become habitual, AD reserves the right to discontinue the provider/patient relationship. Acknowledgements: I have read and understand the above AD Financial Policy. I have been given the opportunity to ask any questions and have agreed as initialed above. I further understand that refusal to sign or comply with the above policies will result in being released from the practice (using the guidelines as applicable by law). Print Patient Name Sign Patient Date Print Guardian Name Sign Responsible Party Date ADF

615 1 st Street North, Alabaster 1320 Woodfin Lane, Clanton Phone: (205) Fax: (205)

615 1 st Street North, Alabaster WELCOME TO TRUE DERMATOLOGY. PLEASE FILL OUT ALL PERTINENT SECTIONS AND SIGN WHERE INDICATED. TODAY S DATE: / / Last Home Phone#: Check Preferred Contact Number First M.