PATIENT INFORMATION. Race: Ethnicity:

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PATIENT INFORMATION Last name: First: MI: Today s Date: SS#: Mailing Address: Date of Birth: City: State: Zip: Sex: Primary Phone: Home Work Mobile Secondary Phone: Home Work Mobile Tertiary Phone

1 PATIENT INFORMATION Last name: First: MI: Today s Date: SS#: Mailing Address: Date of Birth: City: State: Zip: Sex: Primary Phone: Home Work Mobile Secondary Phone: Home Work Mobile Tertiary Phone Home Work Mobile Preferred Language: English Spanish Other, please specify: Employer: Emergency Contact: Male Female Occupation: Relationship: Emergency Contact Phone: Home Work Mobile Race: Caucasian Asian Native Hawaiian Black or African American American Indian or Alaska Native Other Marital Status: Single Married Divorced Widowed Domestic Partner Separated Unmarried Other Ethnicity: Multiracial Hispanic or Latino Not Hispanic or Latino Unknown or do not wish to specify RESPONSIBLE PARTY INFORMATION PLEASE COMPLETE THE SECTION BELOW IF SOMEONE OTHER THAN THE PATIENT IS RESPONSIBLE FOR THE BILL Last name: First: MI: Primary Phone: Home Work Mobile Mailing Address: Secondary Phone: Home Work Mobile City: State: Zip: Employer: Date of Birth: SS#: Occupation: Primary Insurance Company: ID Number: Group Number: MEDICAL INSURANCE INFORMATION Secondary Insurance Company: ID Number: Group Number: Name of Insured: Relationship to patient: Name of Insured: Relationship to patient: Insured Date of Birth: SS#: Insured Date of Birth: SS#:

2 Goodskin Medical History and Intake Form Page 1 Name: DOB: Today s Date: Referring Doctor Name: Referring MD Location : Primary Care Doctor: Primary Care MD Location: Preferred Pharmacy: Phone: City or Zip Code: Past Medical History: (Please circle all that apply) Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation BPH (benign prostatic hyperplasia) Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Heart Attack - Year Hepatitis: Type High Blood pressure HIV/AIDS Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Phlebitis / Blood Clots Prostate Cancer Radiation Treatment Seizures Stroke Additional medical history: Are you currently: (circle) Pregnant / Breastfeeding List all surgical procedures in the last year: Skin Condition History: (Please circle all that apply) Acne Actinic Keratosis Basal Cell Carcinoma Year: Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Year: Poison Ivy Precancerous Moles Psoriasis Squamous Cell Carcinoma Year: Lupus skin or systemic Other: Do you wear sunscreen? Yes No - If yes, what SPF? Do you tan in a tanning salon? Yes No Has anyone in your family had Melanoma? Yes No - If yes, which relative(s): Does anyone in your family have (circle): Asthma / Hay Fever / Dry Skin If yes, which relative(s): What is the best number to call for results? Ok to leave a detailed message? Yes / No

3 Goodskin Medical History and Intake Form Page 2 Medications please list all prescriptions, vitamins, herbs and over-the-counter meds or provide these on a separate page Medication Dosage Medication Dosage Drug Allergies: Please list all allergies and reactions or circle: No Known Drug Allergies Drug Allergy Reaction Drug Allergy Reaction Tobacco Use: (please circle one) Current smoker - Packs per day: Years Smoking: Smoked in the past Never smoked Alcohol Use: (circle one) None Less than 1 drink per day 1-2 drinks per day 3+ drinks per day Do you have any blood disorders? Yes No Do you have problems with scarring or healing? Yes No Any previous reaction to local anesthetic? Yes No Alerts: (Please circle all that apply) Allergy to Adhesive Allergy to lidocaine Artificial heart valve Artificial joint replacement where: Defibrillator History of MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heartbeat with epinephrine Pregnant or currently trying to get pregnant? Yes / No Do you give Goodskin Dermatology permission to discuss your medical information with your family/friend/advocate? Name: Relationship: Phone Number: I consent to having photographs taken which will only be used to document my care/condition and for teaching. Patient Signature ***I verify that the information on this form is correct to the best of my knowledge (please sign below)*** Patient Name: (please print) Date: Signature: Version 3 : 08/16/16 For Staff use Only Reviewed by:

4 OUR FINANCIAL POLICY Thank you for choosing us as your health care provider. We are committed to providing quality medical care. Please understand that the payment of your bill is considered part of your care plan. We ask that you read and sign this Financial Policy prior to any treatment. You may be asked to sign this page again as it may be updated. Please let us know if you have any questions. We will verify your insurance coverage at every visit. It is the patient s responsibility to supply all current insurance cards. We may ask for a copy of your driver s license or picture identification issued from DMV for identity verification. If you do not have insurance, or cannot provide proof of insurance at the time of service, a payment in full is required at the time of service. An equal fee to the amount of the copay may be assessed for any co-payment not made at the time of service. We accept cash, checks, Visa, Discover, American Express and MasterCard. A $25 fee will be assessed for returned checks. Unless otherwise requested, Goodskin Dermatology will not issue refund checks if the amount is under $10.00; instead, those amounts will be applied to future services. If your account is sent to collections for non-payment future services will be provided on a cash only basis. If your insurance requires a referral from your Primary Care Provider (PCP) to see another physician, it is your responsibility to obtain a referral/authorization prior to your appointment. Any unauthorized charges will be your responsibility. The adult accompanying a minor to a visit and the legal parents/guardians are responsible for full payment. We will not be involved in negotiating between parents in custody disputes. When labs, x-rays, or other tests are ordered by Goodskin Dermatology, you are responsible to check with your insurance company as to where you are authorized to have these studies done. We will not be responsible for any bill if you have a test done at the wrong location. If you are here for multiple procedures, the provider will determine whether or not to perform all these procedures during the same office visit or to schedule them at a future date. We cannot guarantee multiple procedures on the same day of service. Your insurance company may have one co-payment for the office visit and a second co-payment for the actual procedure. In addition, if we provide a non-covered service during the same visit as a medical dermatology encounter, then you will have two separate charges. All procedures (such as biopsies, liquid nitrogen/freezing, benign removals, skin tags, etc.) are billed separately and generally fall under deductible. As a courtesy to our patients, we will submit claims to your insurance carrier for you. For those plans that we participate in, we will also submit secondary and/or tertiary claims. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered by your particular plan. Patients are responsible for knowing the details/rules of their health plan(s), as we cannot change our coding in an attempt to obtain payment. I hereby authorize Goodskin Dermatology, to release any medical information required in the course of examination and treatment and permit payment directly to them any benefits due for their services rendered. I recognize and accept responsibility for services rendered regardless of insurance coverage. This includes, but is not limited to, co-payment, co-insurance, deductible, and noncovered services. ***I have read, understood, and agree to the Financial Policy (above) *** Name of Patient or Responsible Party (Please Print) Signature of Patient or Responsible Party Relationship to Patient Date MEDICARE AUTHORIZATIONS I request that payment of authorized Medicare benefits be made either to me or on my behalf to Goodskin Dermatology for any services furnished to me by their providers. I authorize any holder of medical information about me to release to the Health Care Administration and its agents any information needed to determine these benefits or the benefits payable for related services. Signature of Patient or Responsible Party Date

5 ACKNOWLEDGEMENT AND CONSENT I understand that Goodskin Dermatology (referred to below as This Practice ) will use and disclose health information about me. I understand that health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions and similar types of health-related information. I understand and agree that This Practice may use and disclose my health information in order to: Make decisions about and plan for my care and treatment Refer to, consult with, coordinate among and manage along with other healthcare providers for my care and treatment Determine eligibility and my insurance coverage, submit bills/claims and other insurance-related information to my insurance companies or others who may be responsible to pay for some or all of my health care Perform various office, administrative and business functions that support my physician s efforts to provide me with, arrange and be reimbursed for quality, cost-effective healthcare. I understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is knows as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice s Notice of Privacy Practices in effect will be posted in waiting/reception area. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above. By: (Patient signature) Today s Date: And Patient s Name (printed): - OR - By: (Patient representative) Date:

6 AUTHORIZATION FOR COMMUNICATIONS The Goodskin Dermatology practice would like to offer patients the option of receiving appointment notifications via . We want to make sure you know that communications between Goodskin Dermatology and our patients will not be encrypted and therefore are not considered secure communications. communication is a convenience and is not appropriate for emergencies or time sensitive appointment requests. Authorize Notification I, authorize Goodskin Dermatology to Communicate with me via the address provided below. address: (please print) Change Address I am changing the address to be used for communications, and my new address: (please print) I no longer wish to communicate via Patient/representative signature Date Patient s printed name Date of Birth Patient representative s name Relation

PATIENT INFORMATION Date

PATIENT INFORMATION Date Please Complete All Sections Legal Name of Patient Age (Last) (First) (Middle) Date of Birth SSN Gender Marital Status Mailing Address (Street/PO Box) (Apt#) (City) (State) (Zip)