Name: LAST FIRST MIDDLE INITIAL. Address: City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation:

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Rosaline Osborne
5 years ago
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1 Today s Date: Name: LAST FIRST MIDDLE INITIAL City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation: Mailing Address (if different): City: State: Zip: Primary Care Physician: Phone: City: State: Zip: Pharmacy: Phone: City: State: Zip: May we contact you regarding upcoming specials and events by ? Yes or No address: (Please print clearly)

2 HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED. PLEASE REVIEW IT CAREFULLY. Dermatology of the Berkshires, P.C. will use your medical information for the following: 1. TREATMENT: Including providing your medical records to consulting clinicians and insurance companies. 2. PAYMENT: Dermatology of the Berkshires, P.C. will file necessary claims to insurance companies in your name to obtain payment. They may request part or all of your medical record to pay the claim. 3. HEALTH CARE OPERATIONS: Any others involved in your healthcare. The entire HIPAA POLICY NOTICE of Dermatology of the Berkshires, P.C. is posted in the waiting room for your perusal. In conjunction with these privacy practices you will need to provide us with the following information: 1. Name of person(s) Dermatology of the Berkshires, P.C. may speak to regarding your health (i.e. spouse, child, etc. including phone number.) 2. May Dermatology of the Berkshires, P.C. leave a message regarding your health or an upcoming appointment on your answering machine? YES NO Signature of Patient or Legal Guardian Print Patient s Name or Legal Guardian Witness Relationship to Patient Patient s Date of Birth Date

3 INSURANCE/PAYMENT INFORMATION Name: DOB: Thank you for choosing Dermatology of the Berkshires, P.C. for your health care needs. Along with providing you with quality service, Dermatology of the Berkshires, P.C. would also like to assist you with your billing needs. Please read the provisions below and mark the billing class that represents you: 1. Medicare only. Dermatology of the Berkshires, P.C. will file Medicare for you. Dermatology of the Berkshires, P.C. accepts assignment; however, you will still be responsible for the 20% that Medicare does not cover. 2. Medicare/Supplement. Dermatology of the Berkshires, P.C. will file both insurances. However, claims denied, rejected or partially paid by your supplemental carrier will be your responsibility in 30 days. 3. HMO. Dermatology of the Berkshires, P.C. will file to your insurance carrier. It will be your responsibility to obtain necessary authorization by your primary care physician. Visits not authorized will be your responsibility. You will be responsible for your copayment. 4. PPO. Dermatology of the Berkshires, P.C. will file to your insurance carrier. You will be responsible for any coinsurance, copayments and deductibles. Patients going out of their network will be responsible for payment at a higher rate. X 5. Self-Pay. Payment is due at the time services are rendered unless prior arrangements have been made. Dermatology of the Berkshires, P.C. will accept cash, checks, Visa and MasterCard. Monthly statements will be sent to advise patients as to the status of their account. I understand the billing procedures of Dermatology of the Berkshires, P.C. and agree to pay any balances that are my responsibility. Balances unpaid will result in collection actions. Signature: Date: PAYMENT POLICY: In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. For those patients, applicable copayments and deductibles will be collected. We accept payment in the form of cash, check or credit card. In the event of hospitalization or major procedures, our office may file with the appropriate insurance. However, before such claims are filed, coverage will be preverified and you will be asked to pay any unmet deductible, non-covered services and copayments. In the event that your account must be turned over to collections, a $20.00 collection fee will be added to your account. Your signature below signifies your understanding and willingness to comply with this policy. Signature: Date:

4 COSMETIC MEDICAL INFORMATION NAME: DOB: AGE: DATE: Reason for visit: MEDICAL HISTORY: Are you under the care of a physician at this time? Yes No Please check any conditions below that you have: Cardiac problems (pacemaker of defibullator) High Blood Pressure Kidney disease Surgical Implants Keloids/Scarring Diabetes Bleeding disorder/bruise easily Impaired healing Clots Seizures Cancer Vitiligo Rosacea, eczema, psoriasis or skin cancer Arthritis Hepatitis Skin disorders or lesions Cold sores/fever blisters Thyroid disease Hormone imbalance (PCOS) HIV/immunosuppression Other Are you pregnant, nursing or contemplating pregnancy at this time? Yes No Do you smoke? Yes No If yes, how much? Do you drink alcohol? Yes No If yes, how many drinks/daily/weekly? Do you exercise? Yes No If yes, How? Do you follow a special diet? Yes No What? On average, how much sleep do you get per night? SURGICAL HISTORY: Please list all surgeries and approximate dates: IPL/LASER HISTORY: Please list treatments, location and approximate dates: LIPOSUCTION HISTORY: Please list treatments, location, and approximate dates: LEG VEIN HISTORY: Please list any vein stripping, sclerotherapy, or laser vein treatments and approximate dates: COSMETIC HISTORY: Have you had any of the following injections or fillers? Please check all that apply. Collagen Restylane/Perlane Sculptra Juvederm Botox Dysport Other Date of last treatment:

5 MEDICATIONS: Please list any prescription drugs, dietary supplements, herbal remedies or other over-the-counter medications that you take: Have you ever had Accutane or gold therapy? Yes No ALLERGIES: Are you allergic to any medicines, foods or products? Yes No If yes, which ones: Have you ever had an allergic reaction to any of the following? Please check all that apply. Latex Lidocaine Bandaids Anesthesia Topical anesthetics Antibiotic ointments FAMILY HISTORY: Do you have family history of skin disorders (such as eczema, psoriasis, skin cancer, keloids/scarring), autoimmune diseases, bleeding disorders, clotting disorders, varicose veins and/or excessive hair? Yes No SOCIAL HISTORY: Occupation: Hobbies: SKIN TYPE: Ancestry: Which of the following best describes your skin reactions when you are in the sun? Always burns, never tans Rarely burns, always tans Always burns, sometimes tans Sometimes burns, always tans Are you tan? Yes No Please check: Sun tan Tanning bed Self tanner Spray tan Do you plan to go on vacation in the near future? Yes No Do you wear sunscreen? Never Sometimes Always What SPF? What skin care products do you use (cleanser, moisturizers, retinoids, or other anti-aging cosmeceuticals? Do you have any tattoos or permanent makeup? Yes No Do you have any beauty marks? Yes No Do you have problems with hypo or hyperpigmentation (lightening or darkening of the skin)? Yes How did you hear about this office: Doctor Newspaper/magazine Friend/Family Berkshire Bride Website Other Phone book No Signature: Date:

PATIENT INFORMATION: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) ADDRESS: Street Address City State Zip Code

PATIENT INFORMATION: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) ADDRESS: Street Address City State Zip Code PATIENT INFORMATION: Date: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) E-MAIL ADDRESS: ADDRESS: Street Address City State Zip Code BIRTHDATE: / / AGE: SSN: SEX: M F OCCUPATION: