1C SAKAMOTO, M,D, QUEENS PHYSICIANS OFFICE BHDG III 1 650- S, BERETANIAST. -SU1TC 603 HONQUJLU.HI 'S6B13 PR; (808) 447-7454 FAX'; {80S) 447-7458 PATIENT REGISTRATION FORM Patient Name: Date of Birth: Gender: D M D F Last First Ml Marital Status: Social Security #:. Preferred Language: D English/ D Other_ Home Phone #: Mobile Phone #: (circle preferred day time phone #) Mailing Address: Billing Address: (if different from Mailing Address) _Apt#:. _Apt#:. _City:. _City:. Emergency Contact: Name Relationship Phone # Email: _***/VOT : Patient Portal Access is set up via email. A link to our patient portal is also found on our website: (www.sakamotodermatology.com) BILLING INFORMATION (if different from abovei: NOTE: Patients under 18 must be accompanied by a parent/guardian, or have an "Authorization to Treat a Minor" form on file Responsible Party Name: Date of Birth: Gender: D M D F Relationship to Patient: (circle one) Spouse / Parent / Other:_ Home Phone #: Mobile Phone #: Email: (circle preferred daytime phone#) INSURANCE INFORMATION: In order for us to file a claim on your behalf, this section must be completed in its entirety, and a valid insurance card is required upon check-in. CD No Insurance/Self-Pay 1. PRIMARY 2. SECONDARY 3. TERTIARY Insurance Company: Subscriber Name: Relationship to Patient: DSelf DSpouse DParent DSelf DSpouse DParent Subscriber Date of Birth: Subscriber Address: DSelf DSpouse DParent (Street, City, State, Zip) Subscriber ID#: Group Name/ft: My signature below indicates that I have received, reviewed, and agree to the policies set forth on the forms titled: (1) Financial and Office Policies, and (2) Notice of Privacy Practices. I attest that this form is accurate and complete to the best of my knowledge. I hereby authorize the release of any medical information necessary to process claims pertinent to my care with Greg K. Sakamoto, MD and I authorize my insurance benefits to be paid directly to this practice and acknowledge that I am financially responsible for any unpaid balance. Responsible Party Signature Date
K, SAKAMOTO, QUEENS PHYSICIANS. OFFICE BLDG 111 8S& S, BERCTANIAST, SUITE 603 HONOUJUJ, HI S6613 PH; $08)447-7454 FAX: {&08J 447-7456 WWW,SAKAMOTOC«RMATOiO(3iY,CO»v< Patient Medical History Form (1 of 2) NAME: Primary Care Physician: DATE OF BIRTH: Referred by Physician?: Yes / No Physician Name: If not referred by Physician, how did you hear about us? Reason for today's visit: Past Medical History: (please circle all that apply) / D None Anxiety Coronary Heart Disease Arthritis Artificial Joints Asthma Atrial Fibrillation BPH (Benign Prostatic Hyperplasia) Bone Marrow Transplant Breast Cancer Colon Cancer COPD (Emphysema) Other: Depression Diabetes End Stage Renal Disease GERD (Acid Reflux) Hearing Loss Hepatitis B / C Hypertension HIV/AIDS Hypercholesterolemia Past Surgical History: (Please list any past surgeries) / D None Appendix Removed Bladder Removed Mastectomy (Right, Left, Both) Heart Transplant Lumpectomy (Right, Left, Both) Breast Biopsy (Right, Left, Both) Skin Biopsy MOHs Skin Excision Kidney Transplant Colectomy: Colon Cancer Resection Colectomy: 1BD Ovaries Removed: Endometriosis Joint Replacement (within last 2 years) Other: PTCA Mechanical Valve Replacement Biological Valve Replacement TURP Breast Reduction Breast Implants Kidney Biopsy Kidney Removal (Right, Left) Spleen Removal Gallbladder Removal Joint Replacement, Hip (Right, Left, Both) Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement Ovaries Removal: - Ovarian Cancer Prostate Removal: -Prostate Cancer -Prostate Biopsy Testicle Removal (Right, Left, Both) Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Kidney Stone Removal Colectomy: Diverticulitis Ovaries Removed: Cyst Skin Disease History: (please circle all that apply) / D None Acne Blistering Sunburns Actinic Keratosis Dry Skin Autoimmune Diseases Eczema Basal Cell Carcinoma Flaking or Itchy Scalp Other: Melanoma Precancerous Moles Psoriasis Squamous Cell Carcinoma
K, SAKAMOTO, M.5. QUEENS PHYSICIANS OFFICE BLDG HI 660 S, BERETANIAST, SUTE 603 HQNQUJm HI '86813 PH; $09) 447-7454 FAX: f085.447-7456 Patient Medical History Form (2 of 2) Do you wear Sunscreen? YES / NO If YES, what SPF?. Do you tan in a tanning salon? YES / NO If YES, how often? _ Do you have a family history of melanoma? YES 7 NO If YES, which relative(s)? Any other family history of skin disease: Medications: Please list all current medications (name and dosage) or provide list 0 None Allergies: Please list all allergies and the reaction you experience D No Known Drug Allergies Social History: Please circle all that apply: Where were you born and raised?: Occupation/Workplace/School: Marital Status: Cigarette Smoking: Never smoked Quit: former smoker Smokes less than daily Smokes daily Recreational Drug Use: YES / NO Alcohol Use: None Less than 1 drink/day 1-2 drinks/day 3 or more drinks/day Pregnant or planning to become pregnant? YES / NO if PREGNANT, how many weeks?:_ Review of Systems: (please circle all that apply) Problems with bleeding History of rash Artificial joints Joint ache Problems with healing Headaches Blood thinners Pacemaker Problems with scarring Artificial heart valve Defibrillator Family History: (ex. Diabetes, Hypertension, Breast Cancer)_ Preferred Pharmacy: (prescriptions will be faxed to the pharmacy listed) Do we have permission to leave messages on: (please circle all that apply) Home / Work / Cell Ok to discuss medical condition(s) w/ member(s) of your household (Name and Relationship) I attest that this form is accurate and complete to the best of my knowledge. (Patient/Parent/Guardian Signature) (Date)
Financial and Office Policies for the Office of Pr. Greg K Sakamoto: Payment Terms; Medical insurance companies may pay for all, part, or none of the charges for your treatment. We file insurance forms directly to insurance companies, but you must provide complete and updated insurance information or you will be responsible for the full amount due. Please ensure that we have a copy of your current insurance ID card, it is also your responsibility to have a current referral from your primary care physician and current authorization from your insurance company on file with us, if so required by your insurance carrier. Our office is not responsible for unauthorized visits or treatments and unfortunately, if not covered, you will be billed directly for these charges. All insurance co-payments and any outstanding patient balance on your account must be paid at the time of your visit. Cosmetic procedures; Cosmetic procedures are not covered by insurance and are payable at or prior to the time of service. We accept cash, personal checks, debit and credit cards (VISA/MC/Discover, and American Express). There will be a fee of $25 for any returned checks, if your account is over 90 days old with no payment activity, we will begin assessing late fees of up to $5/month, and your account may be turned over to a collection agency. To avoid this, please pay at the time of the visit or mail in payment for any outstanding balance by the due date. Late/No Show; Patients who are more than 15 minutes late may be asked to reschedule their appointment. If you need to cancel an appointment, please call us as early as possible and no later than 24 hours prior to your scheduled appointment or it will be considered a "no show". After two no-show appointments in one year, you may be charged a $25 no-show fee thereafter, PlMSJUi We require that each patient (or guardian) present a photo ID issued by a local, state, or federal government agency, in order to protect the patient against identity theft for services. Prescription Renewals: With the Doctor's approval, certain prescriptions may be renewed by phone. If you have not been examined in the last 3 months, you may be asked to make an appointment to evaluate your current condition. Dr. Sakamoto renews most medications for a 3-month period only. This is to ensure that you are using the best, most effective medication and dose for your condition. Refills may be requested by calling our office at (808) 447-7454. If you leave a message, be sure to indicate: (I.) Your name and phone number (2) The name of the medication (3) Dosage (rug) (4) How often you take it (5) The pharmacy you are using (Jf>4fftinjj htfffrmation; As a new patient, you are asked to complete information forms. Please take the time to complete these forms as accurately as possible. Please notify us promptly of any changes to your contact information (address, phone, email, etc) or insurance. We want to ensure that your medical records are always accurate and up-to-date. It is vital that you inform Dr. Sakamoto of any new medications and medical conditions each time you visit. Should you suspect that you are pregnant, inform us immediately. At each visit, also remind us of any drug allergies, use of anticoagulants, or the presence of a cardiac pacemaker
GREG K. SAKAMOTO, M.D. QUEENS PHYSICIANS OFFICE BLDG III 550 S BERETANIA STREET, STE 603 HONOLULU, HI 96813 PH: (808) 447-7454 FAX: (80S) 447-7456 WWW.SAKAMOTO.COM HIPAA Notice of Privacy Practices for Greg K. Sakamoto. M.D. LLC THIS NOTICE EXPLAINS HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW. The Health Insurance Portability and Accountability Ace (H)PAA) of 1996 was created by the federal government to ensure that all medical records and other personally identifiable health information be kept confidential. This notice describes how we may use or disclose your protected health information (PHI) for the purposes of treatment, payment and for other purposes that are permitted or required by law. It also describes your rights with regards to your health information. I. Our Legal Responsibilities Regarding Your Protected Health..Information We are required by law to maintain the privacy of your health information and to provide you with a description of our privacy practices and legal duties regarding this information, We reserve the right to change any of the terms of this notice at any time within HIPAA compliance. If we change our notice, the updated version will be posted on our website at www.sakamojgdernriatologv,com. it. Uses and Disclosures of Protected.Health Information Your protected health information may be used and disclosed by the staff for the following purposes: 1. Treatment; We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We may also disclose your health information to other physicians who may be treating you. Additionally we may from time to time disclose your health information to another physician who we have requested to be involved in your care. 2. Payment: We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example, we may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service. 3. Health Care Operation: We will use and disclose your protected health information to support the business activities of our practice. For example, we may use medical information about you to review and evaluate our treatment and services or to evaluate our staffs performance while caring for you. In addition, we may disclose your health information to third party business associates who perform billing, consulting, or transcription services for our practice. 4. Health Related Services: We may use your information to contact you about health related services including appointment reminders, lab results, and possible treatment options 5. When we are unable to obtain your authorization: We may use or disclose your information in situations when you are unable to provide us with your permission. For example, if you are unconscious and in need of emergency treatment, and we believe you would consent to the use and disclosure of your PHI, we will use and disclose this information. 6. Disclosures required by law: We will use and disclose your protected health information when required to by federal, state, or local law. You may request an accounting of such disclosures at any time. 7. Public health risks: We will use and disclose your protected health information to a public health authority that is permitted to collect or receive the information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority, 8. Serious threats to health or safety: We may disclose your PHI when necessary to prevent or reduce a serious threat to your safety and health, or to the safety and health of another individual or to the public, This information may only be disclosed to a person or organization able to help prevent the threat. 9. Government purposes: We may disclose information of members of the United States military, or of veterans of the United States military. Additionally, we may disclose your information to federal officials for
6RE6 K- SAKAMOTO, QUEENS PHYSICIANS OFFICE BLDG III 550 S BERETANiA STREET, STE 603 HONOLULU, Hi 96813 PH: (808) 447-7454 FAX: (808) 447-7456 WVvW.SAKAMOTO.COM intelligence and national security activities authorized by law including the protection of the President of the United States 10. Worker's compensation purposes: We may use and disclose your protected health information for worker's compensation or similar programs that provide benefits for work-related injuries or illness in accordance with state law. 11. Inmates: We will use and disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with health care, to protect the health and safety of others, or for the safety and security of the correctional institution, 12. Disclosure to family, or others: We may release your information to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the physician's office for treatment. In this example, the babysitter may have access to this child's medical information, III. Your Rights Regarding Your Protected Health Information You have the following rights with regards to your PHI: 1. The right to request restrictions on uses and disclosures of this information: You have the right to request restrictions on certain uses and disclosures of your health information. You may ask us not to use or disclose any part of you protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must specifically state the restriction requested and to whom it applies. If we do agree to the requested restriction, we may not use or disclose your protected health information except when otherwise required by law, or when it is needed to provide emergency treatment. Requests for restrictions must be in writing to our office. 2 The right to receive confidential communication of your PHI: You may request to receive communications of your health information from us by alternative means or at alternative locations. For example you may request that we contact you with information at home rather than at work, 3. The right to inspect and copy your PHI: You have the right to inspect and obtain a copy of your health information. Your health information consists of your medical records and billing records and any other records that your physician and the practice use for making decisions about you. All requests must be submitted in writing to our office, 4. The right to amend your health information: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information by submitting a request in writing. You have the right to request an amendment for as long as we keep the information. 5. The right to receive an accounting of disclosures of your PHI: You have the right to request an accounting of our disclosures of medical information about you except for certain circumstances, including disclosures for treatment, payment, health care operations or where you specifically authorized a disclosure. 6. The right to a paper copy: You have the right to a paper copy of this notice, 7. The right to file a complaint: If you feel your privacy has been violated by our practice you may file a complaint at any time to our office.
6RB6 K- SfiKfl/WOTO, /H-&- QUEENS PHYSICIANS OFFICE BLDG III 550 S BERETANIA STREET, STE 603 HONOLULU, HI 96813 PH: (808) 447-7454 FAX: (808) 447-7456 WWW.SAKAMOTO.COM AUTHORIZATION TO TREAT A MINOR CHILD NOT ACCOMPANIED BY PARENT OR LEGAL GUARDIAN PATIENT (NAME OF MINOR UNDER 18) '._ DATE OF BIRTH: TO: OFFICE OF GREG K. SAKAMOTO, MD LLC 'Please initial the applicable statements below: initials! authorize the following individuals ns years or oideo to accompany rny child to your office to seek medical treatment (which includes sharing medical information regarding child), and provide consent for such treatment: Name: Name:., Name: Relationship^ Relationship: _ Relationship:^ I understand that my minor child (under the age of 14) will not be seen by physician unless accompanied by a parent, legal guardian, or an individual listed above. initials I permit my teenage child (14 years and older) to attend his/her appointment alone without my presence and authorize treatment for rny child. This includes providing a history of present illness/condition, disclosure of protected health information, and responsibility for relaying any diagnosis, treatment, or prescription(s) to the parent or legal guardian listed below. I agree to be available by phone and to be financially responsible for all co-pays, coinsurance, and deductibles. Print Name of Parent/Legal Guardian Signature of Parent/Legal Guardian Date