Natural Image Skin Center Registration Form

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Jeremy Reed
6 years ago
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Natural Image Skin Center Registration Form New Patient Name Change Address Change Insurance Change Please present ALL Insurance cards to the receptionist.

1 Natural Image Skin Center Registration Form New Patient Name Change Address Change Insurance Change Please present ALL Insurance cards to the receptionist. If patient is a minor, and you are not the legal guardian, please speak with the receptionist immediately. Thank you. Patient Information: Please Complete All Fields Using Legal Names of the Parties Involved. Name: (First) (MI) (Last) Date of Birth: Age: Sex: Male Female Mailing Address: City: State: Zip: Home Phone: Work: Cell: Address: Social Security #: - - Full time Student? YES Part time Student? YES Marital Status (please circle) Single Married Separated Divorced Widowed Primary Care Physician: Pharmacy: Profession: Employer s name: Employer s phone: Emergency contact name/relation to patient: Emergency contact phone: Insurance Information: Primary Insurance Carrier Name: Secondary Insurance Carrier Name: If Patient is Under another Person s Insurance Plan, Please Provide the Insured s Information: Name: (First) (MI) (Last) Date of Birth: SS# - - Relationship to the Patient: Mailing Address: Home Phone: Work: Cell:

2 Patient Release: Must be signed by patient if over 18 or by legal guardian of patient under 18. I certify that the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare) for purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I certify that I hereby authorize Natural Image Skin Center, its providers and staff to provide my minor child in my absence with examinations and basic treatments for which additional consents are not required. I understand as the legal guardian of this child I am required to be physically present to consult with the provider on any procedures which require separate consent such as surgery, biopsy, or wart destructions. I understand additional written consent may be necessary for these types of procedures and that the legal guardian must be present for such consent. Signature: Today s Date:

3 Past Medical History: (please circle all that apply) Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood pressure HIV/AIDS High Cholesterol Thyroid Problems (Hyper or Hypo) Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Pacemaker NONE Other: Past Surgical History: (please list all) Skin Disease History: (please circle all that apply) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer NONE Other:

4 Melanoma: Mother Father Sister Brother Daughter Son Other Do you wear Sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes No Medications: (Please write ALL current medications) Allergies to Medications: Cigarette Smoking: Never Smoked Quit: Former Smoker Current Smoker

5 Please check off any items that CURRENTLY apply to you: o allergy to adhesive o allergy to topical antibiotic ointments o artificial joints within past two years o defibrillator o pacemaker o rapid heartbeat with epinephrine o problems with bleeding o problems with scarring (hypertrophic or keloid) o immunosuppression o chest pain o night sweats o thyroid problems o blurry vision o bloody stool o joint aches o neck stiffness o seizures o shortness of breath o anxiety o allergy to lidocaine o artificial heart valve o blood thinners o MRSA o premedication prior to procedures o pregnancy or planning a pregnancy o problems with healing o rash o hay fever o fever or chills o unintentional weight loss o sore throat o abdominal pain o bloody urine o muscle weakness o headaches o cough o wheezing o depression

6 Natural Image Skin Center Patient Acknowledgement of Office Policies APPOINTMENT CANCELLATIONS: If I am unable to keep my scheduled appointment, I will call Natural Image Skin Center to cancel or re-schedule my medical appointment at least 24 hours in advance. Cosmetic and Surgical appointments require 48-hour cancellation notice. If I do not call Natural Image Skin Center to cancel my appointment as outlined above, I understand I will be required to pay a $25.00 no show fee for office visit, $50 for cosmetic procedures $ for surgical visit and $200 for Moh s Surgery. CO-PAYMENTS: Co-payments are due and collected on the day of my or my family s appointment. It is my responsibility to know my co-payment amount. INSURANCE REFERRALS: If my insurance plan requires a referral, I understand it is my responsibility to obtain an updated referral from my Primary Care Provider and to make sure that Natural Image Skin Center has the referral before my visit. I understand it is my responsibility to keep track of the number of visits I have used on the referral and the expiration date and obtain new ones as needed. I understand should I fail to have a valid referral for my visit, and I am seen, I will be considered a self-pay patient and will be responsible for all charges incurred. I understand my insurance company will not cover any visit where a valid referral is not in place. Patients who are seen without a referral at the time of visit must provide a credit card on file and will be charged as self-pay. INSURANCE CARDS: We require you to confirm your insurance is current at each office visit. New patients or existing patients with a change in their insurance information must provide a valid insurance card or temporary print out at the time of the visit. Should I be unable to produce this documentation, I understand I will pay in full at the time of service and submit the claim to my insurance company myself. I understand that in signing below, I am responsible for notifying Natural Image Skin Center of any changes to my insurance or contact information and if my plan requires a referral. If the insurance information or referral information I present at my visit is not correct, I understand I am responsible for all charges. ACCOUNT BALANCES: I am responsible for the timely payment of my account balances, co-insurances and deductibles. All balances are due within 30 days of my first billing. Any balance left unpaid after 90 days without attempt at resolution will be considered for collections and may be submitted to a collection agency which will make reports to agencies that will effect my credit. If I am having financial difficulty, I understand I may contact the billing office to discuss a reasonable payment plan. If my account is sent to collections, I understand there will be an additional 15% of the total charges added to the principle balance for administrative fees as well as being responsible for any attorney and court charges that may arise from my account being sent to collections. MINOR PATIENTS: A legal guardian must accompany children under the age of 18 to their initial appointment so that legal forms may be completed and signed. Follow up visits do not require a guardian to be present unless a procedure is being performed that requires a signed consent form. Signature: Date: HIPAA PRIVACY POLICY: Patients over the age of 18 are protected under the Federal Health Insurance Portability and Accountability Act. This Federal Law prohibits any staff member of Natural Image Skin Center from discussing appointments, medication, test results or treatment plans with anyone other than the patient. Often, this causes difficulty for some patients who would like family members or caretakers to obtain information for them. If you would like to permit someone to discuss your medical condition, confirm appointments or obtain results for you, please indicate their name(s) below. Should you wish to update the names provided below, please ask the receptionist for a HIPAA Form. Natural Image Skin Center cannot give any medical information to persons who are not listed on this form. Name of Individual (please print) Relationship to Patient I acknowledge I understand the above office policies and I have received a copy of the practice s Notice of Privacy Practices (if requested) related to the Health Insurance Portability and Accountability Act of Signature: Date:

DERMATOLOGIC CENTER FOR EXCELLENCE ANTHONY S. DEE, MD DANIELLE JOHNSTON, RPA-C LISA PORTER, RPA-C PATIENT REGISTRATION FORM

DERMATOLOGIC CENTER FOR EXCELLENCE ANTHONY S. DEE, MD DANIELLE JOHNSTON, RPA-C LISA PORTER, RPA-C PATIENT REGISTRATION FORM PATIENT REGISTRATION FORM Date Patient Name: DOB: Sex: M F Address: City/State/Zip: Email: Social Security #: Please provide contact information and indicate your preferred contact number: Home Phone: