Patient Update Information Patient Name: Last First D.O.B If your info has not changed since your last visit, please sign the bottom of this page and all the consents for our yearly update! If any of the following has changed since your last visit, please fill out the following information: Address City State Zip Home Phone Cell Phone Email Marital Status S M D W Spouse s Name Primary Care Provider: Name Primary Care Provider: Phone Fax Occupation Student Full-time Part-time Patient s Employer Work Phone Address City State Zip Insurance Information: Policy Member s Name Relationship to Patient Insurance Co. Name Co-Payment Amount $ Policy # Group # Patient Signature Date Please present your insurance card(s) and photo ID to the receptionist along with this completed form. Thank you.
Statement of Patient Financial Responsibility Patient Name D.O.B. Skin Wellness Center of Alabama appreciates the confidence you have shown in choosing us to provide for your health care needs. The services you have elected to participate in imply a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill. You are responsible for payment of any deductible and co-payment/ co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies any part of your claim, or if you or your physician elects to continue past your approved period, you will be responsible for your balance in full. I agree to pay any costs incurred by the Skin Wellness Center of Alabama in collecting any amounts due including, without limitation, collection agency fees and attorney s fees. I have read the above policy regarding my financial responsibility to Skin Wellness Center of Alabama, for providing medical services to me or the above named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Skin Wellness Center of Alabama, the full and entire amount of bill incurred by me or the above named patient; or, if applicable any amount due after payment has been made by my insurance carrier. **All copays must be paid in full at time of appointment. And all deductibles must be current to be seen. ** Patient Signature Date Guarantor Signature Date Co-Pay Policy Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patients to pay EACH VISIT. Thank you for your cooperation in the matter. Patient/Guarantor Signature Date Self-Pay In the event you do not have insurance coverage, we are pleased to offer a self-pay option for our patients. Effective January 1st, 2017 Skin Wellness will charge $150 for a new self-pay patient appointment and $85 per follow-up self-pay appointment. Please let us know when you make your appointment if you would like to utilize our self-pay option. I do not have health insurance and will be responsible for services rendered here at Skin Wellness Center of Alabama. I agree to pay the practice the full and entire amount of treatment given to me or to the above named patient at each visit. Patient/Guarantor Signature Date
Appointment Policy In an effort to keep appointments running smoothly and in a timely manner, the following policies have been implemented. Please completely read the policy before signing. If you have any questions, they may be directed to our office staff. For first office visits, please arrive 15-20 minutes early. New Patient forms must be completed prior to seeing the doctor. These forms are also available on our website at www.skinwellnessal.com under Patient Resources if you wish to complete prior to your office visit. If you are unable to make your appointment, please call 24 hours in advance to cancel. Failure to do so will result in a $50.00 No Show fee. Please be aware that Monday appointments must be canceled by noon on the previous Friday. If you are scheduled for surgery, a procedure for Accutane follow-up and you cancel or no show, we may not be able to reschedule another appointment in a timely manner. Any time that you will be late for an appointment, please call to inform us. If you are running more than 15 minutes late, you may be asked to reschedule if our schedule is tight. We will always try to accommodate as we all run late sometimes. Appointment time reflect the health issues provided to the receptionist at the time the appointment is scheduled (i.e.; is the visit for acne, a mole check, a surgical procedure or a consultation regarding a specific skin and/or cosmetic concerns?). Lengthy delays result from patients asking for additional time to address issues other than those originally scheduled. Please be considerate of those waiting. The Skin Wellness Center of Alabama is committed to timely appointments, so we appreciate your cooperation and understanding on these matters. Patient s Name Date (please print) Signature of Patient or Legal Guardian
HIPAA Patient 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 The Practice may condition receipt of treatment upon the execution of this Consent. This Consent was signed by: Printed Name Patient or Representative Relationship to Patient (if other than patient): Witness: / / Signature Date Printed Name Patient or Representative / / Signature Date
HIPAA Patient Consent Form (continued) I understand that as a part of my healthcare, this practice originates and maintains health records describing my history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I wish to have the following restrictions to the use or the disclosure of my health information: You may release my records to the following family members and physicians: Patient Signature Date
Patient History and Intake Form Past Medical History: (Please circle all that apply.) Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood Pressure HIV/AIDS High Cholesterol Hyperthyroid Hypothyroid Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke NONE Other Past Surgical History: (Please circle all that apply.) Appendix Removed Biological Valve Replacement Bladder Removed Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Coronary Artery Bypass Gallbladder Removed Heart Transplant Hysterectomy Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy (Nephrectomy) Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Lumpectomy (Right, Left, Bilateral) Mechanical Valve Replacement Mastectomy (Right, Left, Bilateral) Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Biopsy Prostate Removed: Prostate Cancer Spleen Removed TURP (Prostate Removal) Testicles Removed (Right, Left, Bilateral) Tonsillectomy NONE Other
Patient History and Intake Form (continued) Skin Disease History: (Please circle all that apply.) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer NONE Other Do you wear sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes Do you have a family history of Melanoma? No Yes No If yes, which relative(s)? Medications: (Please enter all current medications.) Allergies: (Please enter all allergies.)
Patient History and Intake Form (continued) Social History: (Please circle all that apply.) Cigarette Smoking: Currently smokes Has smoked in the past Never smoked Alcohol Use: Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day None Other 65+ Pneumonia Vaccine: (Please circle one.) Yes or No Family Medical History: (Only first degree relatives.) Preferred Language Race Ethnic Group Preferred Pharmacy Name Phone City or Zip Code
Patient History and Intake Form (continued) Review of Symptoms Are you currently experiencing any symptoms? Special Alerts (Please circle all that apply.) Are you pregnant or currently trying to get pregnant? Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement Blood thinners Defibrillator MRSA Pacemaker Require antibiotics prior to surgical procedure Rapid heartbeat with epinephrine Yes No