Welcome to Advanced Dermatology

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Stephanie Townsend
6 years ago
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1 Patients Name Welcome to Advanced Dermatology (First) (Middle) (Last) Today's Date Date of Birth Gender SS# Patient Employer Name City State Phone ( ) Phone ( ) Financial Responsible party (Minors Only) Referring Doctor or Primary Care Doctor (Required) Name Name Phone ( ) Date of Birth Phone Responisble Party SS# Type of Doctor Race Hispanic/LaHispanic/Latino Language [ ] White/Caucasian [ ]American Indian [ ] Yes [ ] No [ ] English [ ] Asian [ ] Native Hawaiian/Pacific Islander [ ] Spanish [ ] Black/African American [ ] Other [ ] Other Emergency Contact [ ] We may leave a message on your answering machine / voic . Name: [ ] We may discuss your medical condition with another person. Phone: ( ) *This requires you to fill out a HIPPA form for our office. Relation: I hearby authorize Advanced Deramatology to examine and treat my child, or me an to perform such diagnostic test and or treatments as may be necessary for the duration of treatment for this injury/illness. I heraby authorize the release of any medical information neceesary to process my Medicare and/or insurance claims and for any benefits payable under my policy be paid directly to Advanced Dermatology. I understand that this information related to the diagnosis and/or treatment of alcohol/substance abuse, psycological/mental health disorders and/or HIV serostatus. I understand that I am responsible for the fees for all services rendered (and equipment/supplies provided) to my child or me. I guarantee payment for the portion of my account for which I am reponsible at the time of service or within the pre-arranged time frame agreed upon by the business office. I agree that, in the event I default and do not pay my balance, reasonable costs of collection, and/or reasonable attourney fees may be added to the amount due on the account and I agree to be financially responsible for those additional charges. Signature of Patient/Responsible Party Date IF PAYING CASH - ASK FOR A RECEIPT. IT WILL BE THE ONLY PROOF YOU HAVE OF PAYMENT. rev

2 FINANCIAL POLICIES We are committed to providing our patients with the best possible dermatology care. As a patient, your clear understanding of our policy is important to our professional relationship. As a courtesy to our patients, we file insurance claims for all non-cosmetic services that are rendered. Your insurance is a contract between you, your employer and the insurance company-we are not party to that contract. It is your responsibility to provide our office with your current medical insurance information and your current medical insurance card(s) at the time of your appointment. We will not bill insurance for coverage presented at a later. It is your responsibility to know and understand the provisions of your medical insurance policy. Our office CAN NOT guarantee payment of your claims; if your insurance company pays only a portion of your claim, or rejects it entirely, you must follow up with your insurance company as any explanation should be made to you, their policyholder. Reduction or rejection of your medical insurance claim by your insurance company does not relieve you of your financial obligation to Dr. Kuriata, Joh Killian, PA-C or Hilary Beyerlein, PA-C. Not all services are covered benefits in all contracts. Insurance companies select certain services they will not cover. Some, and perhaps all, services rendered may be considered "non-covered services" by your insurance company. It is your responsibility to know your plan s provisions and seek appropriate approval prior to your services as coverage varies by insurance company and can vary from policy to policy. If we participate with your insurance, you are responsible for payment of all deductibles, co-payments, co-insurance payments and non-covered services at the time services are rendered. It is your responsibility to know the amount of your co-pay, co-insurance, or deductible-in the event you do not know, we will collect $30.00 at the time of service and refund any overpayment or bill you for any underpayment after your claim is processed. If we do not participate with your insurance company, or if you do not have medical insurance coverage, payment for services is due at the time services are rendered. We accept cash, personal checks, money orders, Visa and MasterCard. Any personal check that is returned for insufficient funds is subject to a $30.00 service fee. In the event there is a balance due from you after your claim is processed, we will send a billing statement to you for payment in full within 15 days. Any accounts past due 60 days will be reviewed for in-office collections and referred to an outside collection agency after 90 days. In the event you default and do not pay the balance due, reasonable costs of collection and/or reasonable attorney fees may be added to the amount due on the account. Patients with a past due balance must make payment arrangements prior to scheduling any further appointments. Any questions, concerns, and/or requests for payment arrangements must be made with business office staff or the practice manager. You may reach the business office staff at (269) or our Billing Service (888) We will file primary and secondary claims for you. We do not file tertiary (third) claims. We must have the explanation of benefits from the primary insurance claim in order to file the secondary insurance claim. We require our patient s, or the patient s financially responsible parties, social security number based on the fact we are extending credit to our patients with participating insurance coverage. In order to offer the courtesy of billing your insurance, rather than payment at the time of service, we must have your social security number. If you do not wish to provide your social security number, you will be required to pay all, or the portion we are readily able to determine to be due after insurance, for your services at the time they are provided. In the event you are unable to keep your appointment, we require 24-hour cancellation notice. We reserve the right to charge a fee for missed or late-cancelled appointments. Advanced Dermatology reserves the right to dismiss any patient that has accumulated three or more missed or late-cancelled appointments. You are responsible for the full cost of any cosmetic procedure at the time of service. We do not bill insurance for cosmetic procedures. CASH Payments: PLEASE ASK FOR A RECEIPT, THIS WILL BE ONLY PROOF OF PAYMENT YOU WILL HAVE. Initial:

3 Medical History Patient Name: Local Pharmacy: Reason for Today's Visit: Are you allergic to any medication? [ ] Yes [ ] No List all medication you are currently taking: Today's Date: Date of Birth: Mail Order Pharmacy: List: Do you have now, or have you ever had diseases or conditions of: (Please check Yes or No) Yes No Yes No Anxiety GERD Arthritus Hearing Loss Asthma Hepatitus Irregular Heart Beat Hypertension Bone Marrow Transplant HIV/AIDS BPH (Beneign Prostate Hypertrophy) Hypercholesterolemia Breast Cancer Thyroid Disease Colon Cancer Leukemia COPD Lung Cancer Coronary Artery Disease Lymphoma Depression Prostate Cancer Diabetes Radiation Treatment End Stage Renal Disease Seizures Pacemaker Stroke Artificial Heart Valve Other: Do you have artificial joints? Have you ever had skin cancer? Has anyone in your family had skin cancer? Do you smoke? Do you use IV drugs? Do you drink alcohol? Received flu vaccine this year? Received pneumonic vaccine this year? Do you use sunscreen? Circle: Biopsy/Basal/Squamous/Melanoma Who? If yes, how much? If yes, how much? If no, why? Patient Signature: Date: 1

4 Name: Date: SKIN DISEASE HISTORY: Yes No ALERTS: Yes No Blistering Sunburns Problems with Bleeding? Dry Skin Problems with Healing? Eczema Keloids or Scarring? Flacky or Itchy Scalp Biologics Use? Poison Ivy Allergy to adhesives Precancerous Moles Allergy to ladocaine? Psoriasis Allergy to Antibiotics? Blood Thinners? Are you trying to get pregnant? MRSA? Are you pregnant? Latex Allergy? SURGICAL HISTORY: (Please list, including s) rev

5 Limited Patient Authorization for Disclosure of Protected Health Information Form 7.31 Please print all information. Form must be signed and d each year. Patient Name: SSN (last four digits): Date of Birth: Entity Requested to Release Information: Purpose of request (who will be authorized to receive information) - I authorize the entity identified above to disclose or provide protected health information, about me to the individual(s) listed below. Who will be authorized to receive information (list the individual/entity who is to receive your PHI): Individual/Entity Name: : Phone: Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above: Entire patient record; or, check only those items of the record to be disclosed: office notes nursing home, home health, hospice, and other physician records lab results, pathology reports record of HIV and communicable disease testing x-rays; record of mental health or substance abuse treatment financial history report (previous 3 years only). Only send the following: Purpose of disclosure (please record the purpose of the disclosure or check patient request): Patient Request Other (please specify): This authorization will expire at the end of the calendar year of your last signature below, unless you specify an earlier termination. You must renew or submit a new authorization after the expiration to continue the authorization. Please list the of expiration if earlier than the end of the calendar year: You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization. The practice places no condition to sign this authorization on the delivery of healthcare or treatment. We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice. You have the right to receive a copy of signed authorizations upon request.

PATIENT INFORMATION. Race: Ethnicity:

PATIENT INFORMATION. Race: Ethnicity: 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