Friendswood Dermatology REGISTRATION INFORMATION Page 1-2. Name First MI Last
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1 Friendswood Dermatology REGISTRATION INFORMATION Page 1-2 Patient Information: Today s Date Name First MI Last Address Street City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Birth date Sex: M F Preferred contact method: Home Phone: Cell Phone: Work Phone: SSN#: Occupation Referring physician Primary care physician Financial Responsible Party (If different from patient): Name Birth date First MI Last SSN#: Home/Cell Phone ( ) Work Phone( ) Address Street City State Zip Relationship to patient Emergency Contact Information: In case of emergency, whom should we notify? Relationship to patient Phone ( ) HIPAA CONSENT - Patient Record of Disclosures I wish to be contacted in the following manner (check all that apply): Home Telephone OK to leave a message with details Leave message with call-back number only Work Telephone OK to leave a message with details Leave message with call-back number only Cell Telephone OK to leave a message with details Leave message with call-back number only If our office is unable to communicate by phone, then Written Communication can be sent to: home address work/office address In my absence, I give authorization for Friendswood Dermatology to leave a message with (Name) (relationship to patient) for matters regarding: my appointment reminders my account such as billing and amount due my treatment/test results If my family member calls the office, I give authorization for Friendswood Dermatology to discuss my medical information with (Name) (relationship to patient)
2 Friendswood Dermatology REGISTRATION INFORMATION Page 1-2 I acknowledge that I have read a copy of the Notice of Privacy Practices for HIPAA. Signature of Patient/Responsible Party Birth date Print Name Date The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitue and adequate record Note: Uses and disclosures for Treatment Records, Payment Information and Healthcare Operations may be permited without prior consent in an emergency. Record of Disclosures of Protected Health Information (This section below is to be completed by Office Staff only when disclosing records) Date Disclosed to Whom Address or Fax No (1) Description of Disclosure/ Purpose of Disclosure By Whom Disclosed (2) (3) (1) Check this box if the disclosure is authorized (2) Type Key: T= Treatments, P= Payment Information; O= Healthcare Operations (3) Enter how disclosure was made: F= fax; P= Phone; E= ; M= Mail; O= Other *see Records of PHI Disclosures in EHR Friendswood Dermatology, Cosmetic, & Skin Cancer Center Dr. C. Paulina Vu 1111 South Friendswood Drive, Ste Friendswood, TX Phone: (281) 482-DERM (3376) Fax: (281)
3 Financial Policy Thank you for choosing Friendswood Dermatology as your health care provider. We are committed to providing excellent health care services to you, our patient. As a part of our personal professional relationship, it is important that you have an understanding of our financial policy. All patients must read and sign this form prior to receiving services. It is your responsibility to provide us with your most current insurance information. If you fail to provide accurate insurance information in a timely manner, your insurance company may deny the claim. If the claim is denied, you will be financially responsible for the services rendered. We must emphasize that, as medical providers, our relationship with you, the patient, and not your insurance company. Your insurance is a contract between you, your insurance company and possibly your employer. It is your responsibility to know and understand the level of services covered by your insurance company. We may accept assignment of insurance after verification of your coverage. Please be aware that some or perhaps all the services provided may not be covered in full by your insurance company. You are financially responsible for services not covered by your insurance company. We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company s arbitrary determination of usual and customary rates. Copayments, coinsurance and/ or deductibles are due at the time of service. We will estimate the amount you owe based on information we receive from your insurance company. However you are responsible for paying the full amount determined by your insurance company once they have paid your claim- regardless of our estimation. It is your responsibility to provide us with your most current billing information. You must provide your most current billing address, all available telephone numbers and any other important contact information. If your address or contact information changes, it is your responsibility to contact us and with the updated information We will send a statement (to the billing address you provide) notifying you if any balances you may owe. If you have any questions or dispute the validity of this balance, it is your responsibility to contact our business office within 30-days after receipt of the initial statement. You can call (281) Payment in full is due upon receipt of the statement. Patient balances not paid in full within 30 days of the statement issue date are deemed past due. Past due account may be subject to a $5.00 monthly late fee and may be referred to a professional collection agency and/or attorney for further collection activity. You will be responsible to pay all collection costs incurred, including attorney s fees and court cost if applicable. If you are not able to pay the balance due in full, you must contact our billing office to discuss a payment schedule. Any late fees already incurred on past due balances will be included in any mutually agreed upon arrangements. If you fail to make payments as agrees upon your account may be referred to a professional collection agency and/ or attorney. You will be responsible to pay all collection costs incurred, including attorney s fees and court cost if applicable. If your account is assigned to a collection agency you will be notified by certified mail that you will no longer be able to receive services from Friendswood Dermatology Cosmetic & Skin Cancer Center, PLLC. Failure to accept this certified letter (and /or to pick it up at the post office) serves a notice of termination of services. In the event you submit payment by check and the bank returns the check unpaid for any reason, we will add $35 to your original balance. In addition, we may seek all additional legal remedies provided to us under Texas law. We may Charge you No Show fee if you fail to cancel or reschedule your appointment at least 24 hours prior to your appointment date. Failure to keep your account balance current may require us to cancel or reschedule your appointment. I UNDERSTAND AND AM WILLING TO COMPLY WITH THE ABOVE POLICIES. Signature of Patient or Responsible Party Print Name Date
4 Friendswood Dermatology History and Intake Form Page 1-4 NAME: DATE OF BIRTH: Past Medical History: (please check all that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism BPH (Benign Prostatic Hyperplasia) Hypothyroidism Bone Marrow Transplantation Leukemia Breast Cancer Lung Cancer Colon Cancer Lymphoma COPD (Emphysema) Pacemaker Coronary Artery Disease Prostate Cancer Depression Radiation Treatment Diabetes Seizures End Stage Renal Disease Stroke GERD (Acid reflux) Valve Replacement Hearing Loss None Other Past Surgical History: (please check all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass PTCA Mechanical Valve Replacement Biological Valve Replacement Heartransplant Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Other None Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed (Right, Left, Bilateral) Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Kidney Biopsy
5 Friendswood Dermatology History and Intake Form Page 2-4 Skin Disease History: (please check all that apply) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Flaking or Itchy Scalp Other None Do you wear Sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes No If yes, which relative(s)? Any other family history: Medications: (Please enter all current medications) Currently not taken medication Allergies: Social History Cigarette Smoking: Alcohol Use: Ethnicity: Language: Never smoked YES Hispanic/Latino English Quit: former smoker NO Non-Hispanic/Latino Spanish Smokes less than daily Other Smokes daily Race: White Black/African American Asian American Indian or Native Alaskan Native Hawaiian/Pacific Islander Other Pharmacy: CVS HEB Kroger Walgreen Wal-Mart Sam s Other location:
6 Friendswood Dermatology History and Intake Form Page 3-4 Describe in the space below your main dermatologic symptoms/problems, how long you have had them, and past treatment(s): Review of Systems: Problems with bleeding Problems with healing Problems with scarring (hypertrophic or keloid) Rash Immunosuppression Fever or Chills Chest pain Wheezing Shortness of breath Blurry vision Hay fever Sore throat Cough Night sweats Unintentional weight loss Joint aches Muscle weakness Neck stiffness Headaches Abdominal pain Bloody stool Bloody urine Pregnancy or planning a pregnancy Latex allergy Adhesive/tape allergy Lidocaine allergy Epinephrine causes rapid heartbeat Defibrillator Pacemaker Other implanted electrical stimulatory device Premedication prior to procedures Artificial heart valve Artificial joints within past 2 years MRSA Blood thinners (Warfarin/Coumadin, Heparin)
7 Friendswood Dermatology History and Intake Form Page 4-4 Cosmetic Consultation Questionnaire Which treatments interest you: (please check all that apply) Botox/Dysport Sclerotherapy (Spider Veins) Chemical Peels Laser Not Sure What are your cosmetic concerns: (please check all that apply) Brown spots Breakouts Skin Discoloration Skin Texture Fine Lines/Wrinkles Skin Care Other Are you currently using any of the following products: (please check all that apply) Retin-A/Tretinoin Valtrex/Zovirax/Acyclovir/Famvir Coumadin/Warfarin Hormone Replacement Birth Control Pills Glycolic Acid/Alphahydroxy Acid Plavix Accutane (within the past 1 year) Aspirin Heparin Vitamins: Antibiotics: Skin Lightening: Acne Medications: Patient Signature Print Name Date Friendswood Dermatology, Cosmetic, & Skin Cancer Center Dr. C. Paulina Vu 1111 South Friendswood Drive, Ste Friendswood, TX Phone: (281) 482-DERM (3376) Fax: (281)
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HIPAA Patient Consent Form
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Name: Mr Ms Mrs Dr Last First Initial. Mailing Address: City: State: Zip Code:
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Patient Information Please Complete All Sections. Responsible Party, if different from patient. In Case of Emergency. Name (Last, First, M.
Patient Information Please Complete All Sections Name (Last, First, M.I) Nickname Date of Birth / / SS# Gender: Male Female Home Address (street, city, state, zip) 2 nd Mailing address (street, city, state,
PATI ENT INFORMATION Date=----~--- First Name: Ml: Last Name: ------------ Date of Birth: Sex: [ ] Male [ ] Female Address: City,State, Zip: Home Phone: Cell Phone:, Work Phone: Email Address: Marital
Patient Name: Todays Date: Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status
Patient Name: Todays Date: *General Patient Information Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Mailing- Address, City, State & Zip *PARENT
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
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Medicare Patient Registration
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Pierre G. Labrecque, M.D. 120 North Miller Street, Building C Santa Maria, CA (805) Office (805) Fax
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**Please be sure to fill out EVERY section thoroughly. Indicate N/A for sections that do not apply to you Name: Street Address: Date: City / State: Zip Code: Date of Birth: Gender: Marital Status: Occupation/Employer:
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PATIENT INFORMATION Please Complete All Sections on All Pages
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Name SS# LAST FIRST MIDDLE INITIAL. Address STREET CITY APT # STATE ZIP. Alternate Address STREET CITY STATE ZIP
Date: Patient Information Name SS# LAST FIRST MIDDLE INITIAL Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed Address STREET CITY APT # STATE ZIP Alternate Address STREET
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM APPOINTMENT DATE & TIME Name Nickname Address: _ STREET CITY STATE ZIP Phone: HOME CELL WORK Date of Birth: Age: Sex: Marital Status: Email: @ Do you wish to receive email/text
PATIENT INTAKE FORM. UNDER 18 years old?: INSURANCE INFORMATION (Please give your insurance card to the receptionist.)
PATIENT INTAKE FORM Primary Care Physician: Specialist Physician: Referred? : Referred By: PATIENT INFORMATION (Please give your I.D. to the receptionist.) Patient s FIRST Name: LAST Name: MI: Preferred
Please Complete All Sections on All Pages. RELEASE OF MEDICAL INFORMATION to other individuals if we are unable to reach you (HIPAA requirements)
Please Complete All Sections on All Pages PREFERRED PHONE # ALTERNATE PHONE #_ EMAIL ADDRESS BIRTH DATE PATIENT S NAME: (Last, First, MI) SEX: PRIMARY ADDRESS (STREET) APT# CITY STATE ZIP -- ALTERNATE
Last Name _ First Name Middle Initial _ Social Security Number: Birthdate Age Sex (Circle one) M F Address _City State Zip Home Phone # Cell Work
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Date. Cell Phone: ( )
Date / / Name: Date of Birth: / / AGE: Last First MI Home Address: City: State: Zip: 2 nd Home Address: City: State: Zip: Email Address: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Is it okay to leave
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NEW PATIENT INFORMATION (PLEASE PRINT)
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PATIENT REGISTRATION
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New Patient Registration
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NEW PATIENT FORM (please print)
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If have a specialist co-pay, we will collect that at time of service.
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Address: Primary Insurance Co. Name: Policy Holder:
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PATIENT REGISTRATION
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PATIENT REGISTRATION FORM. _Apt#:. _Apt#:.
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PATIENT INFORMATION. Race: Ethnicity:
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Minor Patient Information
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NEW PATIENT REGISTRATION FORM
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Mailing / Secondary/ Billing/Guardian/POA address (circle one) City/State/Zip. Home Phone# Cell Phone# Phone Relationship INSURANCE INFORMATION
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PATIENT INFORMATION SHEET. Reason(s) for Visit: (chief complaint)
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Would you like to receive our monthly ed newsletter? Yes! No thanks.
Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON RESPONSIBLE FOR ACCOUNT: MAILING ADDRESS: (CITY)
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Minor Patient Information
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PATIENT INFORMATION Date
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Street Address: Apt. # City State Zip. Employer Name and Address. City State Zip. Name of Spouse or Guardian. Emergency Contact Name and Phone
Patient Name Social Security Number: Date of Birth: Age: Street Address: Apt. # City State Zip Home Phone: ( ) -- Mobile Phone: ( ) -- Employer Name and Address City State Zip Business Phone ( ) -- Occupation
Sex: Male Date of Birth: / / Age: Social Security #: - - Female Address: (Street Address) (Town/City) (State) (Zip)
Mohs Surgery, Cosmetic Skin Surgery, Laser Skin Surgery Amir Bajoghli, MD; Janice Rasmussen, NP-C; Suzanne Adler, PA-C 8130 Boone Blvd, Suite 340, Tysons Corner, Virginia 221822200 Opitz Blvd, Suite 100,
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Patient Information Form
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Name: of birth: : Referred by: ( )*Physician ( ) Patient to Patient ( ) Family ( ) Insurance ( ) Internet ( ) Other: *If referred by physician please give name: Phone: First Last Who is your Primary care
Acknowledgement of Receipt of Notice of Privacy Practices. Benefits to Physician. Release of Information
PATIENT REGISTRATION : Patient Name: of Birth: Marital Status: Last, First Address: City: State: Zip: Street/Apt #/PO Box Home #: Cell #: Work #: Email: Sex: F M SSN #: Referred by: *Physician Patient
Demographic Information
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