Please be aware that payment of all office visits and services are due at the time of your visit.

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1 Dr. David A. Amato All About Faces Community Dermatology 1 West Main Street Hummelstown, PA (717) (717) I would like to take this opportunity to welcome you to Community Dermatology, where my staff and I are committed to offering our patients the most professional and technologically advanced dermatological care available today. We have enclosed our patient information forms that need to be completed, signed and brought with you on the day of your visit. Please be sure to bring your insurance card(s) and photo identification to your appointment. By having this information available to us upon arrival it will help to expedite your check-in process. Please be aware that payment of all office visits and services are due at the time of your visit. I look forward to meeting you and serving all of your skin care needs. Thank you in advance for choosing Community Dermatology/All About Faces. Sincerely, David A Amato David A. Amato, D.O.

2 DAVID A AMATO DO (717) Patient Record Number: Patient Information as of: (Please Print Legibly & Fill In All Fields) Patient s Name Address Last First Middle Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions for contacting you? No Yes Contact How were you Restrictions: referred to us? Age Birthdate SS# Sex Female Male Marital Status Single Married to: Other: Primary Care Physician Patient s Employer Phone Occupation Work Phone Ext: Is it okay to call you at work? Yes No Address Emergency Contact Street & Suite # City State Zip Relationship to Patient Home Phone Work Phone Other Phone Primary Health Insurance Company Policy # Group # Insured: Name Secondary Health Insurance Company Policy # Group # Insured: Name DOB DOB I assign directly to Dr. David A. Amato all benefits payable for services rendered. I authorize Dr. Amato to release any information necessary to secure payment of said benefits for Highmark Blue Shield and to use this signature on all insurance submissions whether manual or electronic. I acknowledge that co-payment is due at the time of treatment, unless other arrangements have been made. I acknowledge that if my insurance carrier is not listed above, I am responsible for payment in full for ofiice visits and procedures. I agree that the presenting parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance and agree to make arrangements for prompt payment. The undersigned verifies that an attempt was made to deliver a copy of the Community Dermatology's Notice of Privacy Policies to the above patient. The undersigned also verifies the Privacy Policy, Financial Policy, and Personal Health Information. I hereby give my permission to Community Dermatology/All About Faces to disclose my personal health information to the personal representative(s) indicated below: Name/Relationship Name/Relationship Witness

3 NAME: Past Medical History Have you or members of your family had any of the following: You Your Family Abnormal Bleeding Acne Anemia Arthritis Asthma Blood Clots Cancer Cold Sores Diabetes Eczema Gall Bladder Disease Heart Disease Hepatitis High/Low Blood Pressure High Cholesterol HIV Liver Disease Melanoma Nervous Disorders Psoriasis Skin Cancer Thyroid Disease David A Amato DO 1 West Main Street, Hummelstown, PA PATIENT HISTORY FORM DATE: List present medications you are taking: (Including herbal and vitamin supplements) Personal Alcohol History: Age Started: Age Stopped: Quantity: Personal Smoking History: Age Started: Age Stopped: Quantity: Tuberculosis Cigarettes Pipe Cigars Allergies Yes Reaction What other Physicians are you currently seeing: Latex Penicillin Local Anesthetic List any other relevant allergies that you are aware of:

4 Community Dermatology All About Faces Finance Policy Thank you for choosing Community Dermatology/All About Faces for your dermatologic care. We are committed to your treatment being successful. Please understand that payment of your bill is considered to be part of our treatment. Full payment is due at the time of service for office visits, treatments and procedures. We accept cash, checks, and debit cards, Visa, MasterCard, Discover, American Express and CareCredit. Insurance: The only insurance company that we do participate with is Highmark Blue Shield (excluding Freedom Blue). We do not participate with any other insurance provider or Medical Assistance Program. As a courtesy we can provide you with the insurance form you need to file your claim with your insurance provider. Highmark patients are responsible for any amount allowed but not paid. We do not bill supplemental carriers. Missed Appointments: We require a 24 hour cancellation notice. Our fee for a missed appointment is $35. In the event that we do not receive a 24 hour cancellation notice, any future appointments at this office will require a credit card number to hold your appointment. I have read, understand and agree to the Finance Policy stated above. X Printed Name Date Updated 02/18/2014

5 David A Amato DO 1 West Main Street, Hummelstown PA HIPAA CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. This Consent was signed by: Printed Name of Patient or Representative / / Date Relationship to Patient (if other than patient)