McDonnell Dermatology, LLC 25097 Olympia Ave Suite 204 Punta Gorda, FL 33950 941-205-3376-Phone 941-205-3379 Fax Patient Care Policy Letter Welcome to McDonnell Dermatology, LLC. Our mission is to provide quality care to all patients. This letter is to better acquaint you to our office policies for our patient care. Patient Medical Information.Form: To help us provide you with the best med ical care, we as k lhat all new patients, and patients we have not seen In the past 3 years, fill out a medical information form. Me~ications: We ask that whenever you come in for an appointment, that you bring a current list of all the medications you are currently taking. You should keep this list in your wallet or purse and share it with other doctors 'you may visit. Whenever you are prescribed a new medication, read any information that might come with it and check with your pharmacist to make sure it does not interfere with any of your other medications. Prescription Refills: If you call for a prescription refill, please be prepared to give the details of the medication needed (i,e., name, strength, quantity, where and how often using, etc.), Please make sure to request during regular office hours and allow up to 48 hours to be called in, longer if you call in the day before a weekend. If McDonnell Dermatology, LLC hasn' t seen you within the past l2 months, you should make an appointment for reevaluation before requesting the additional prescription, with few exceptions. Skin Biopsy and other Lab Test: Sometimes it is necessary to take a skin biopsy and (or) order lab test to help us figure out what is causing a skin condition. You and or your insurance company will get a separate bill from the laboratory. It is very important that you get the results of any test we order (e.g., skin biopsies, blood work. X-rays). After we receive the results, we will call you to discuss them, However, if you don ' t hear from us within 3 weeks from the time of the test was done, it is important that you call us for the results. Referring Doctors: If another doctor referred you to McDonnell Dermatology, LLC, please let us know and our office wi ll send the referring doctor a letter that will provide the details of your evaluation. Referrals: Some insurance companies require that we have a " referral authorization" from your primary care doctor prior allowing our office to see you, on the initial visit or subsequent appointments. If we do not received it by your appointment time. you will need to reschedule. so please make sure that your primary care doctor sends it to us in time, It is very important! Please do not forget. Insurance and Billing Questions: Our current health care system is very complex and it is difficult to keep track of the always-changing insurance company rules and regulations. We will work with you to help resolve problems that may arise from your insurance company (e.g., refusal to pay for certain treatments, lab test, or follow up visits). As a co urtesy to our patients, we file the bills with most insurance companies. However, the involvement of the insurance companies makes the billing process extra complicated. If you have any questions regarding your billing statements, please let us know so we can help you figu re them out. Appointment Cancellations: If you have a change in plans, we will be grateful if you would call and cancel or reschedule your appointment as soon as possible so that other patients can use your appointment time. A 24-hour notice is needed to prevent being charged. You can leave a message on our answering machine if you call after regular office hours, Thank you, Emergent Dermatological Needs: If you have a medical skin condition that you feel cannot wait for the next available appointment, let our staff know and we will make all efforts to accommodate your needs. After hours problems may be handled by calling 941-205-3376 and the doctor on call will contact you directly. IF YOU FEEL YOU ARE HAVING A TRUE MEDICAL EMERGENCY, PROCEED TO THE NEAREST EMERGENCY ROOM FOR MEDICAL CARE. Patient signature, Date,
~ I~ REGI~~ RATION INFORMATION Patient Information: Today's Date Name ~F~irStst-----------------------~MII------~L~as~t---------------------------- Address StStrereetet-------------------------------------~--------------~--~---- City State Zip Home Phone ( Work Phone ( Cell Phone ( Date of Birth Male Female Referring physician Primary care physician -------- SSN ---- --------------------- --------------------------------~------------ Location ------------------------------ ---------------- Current Occupation and or Pre Retirement Occupation Responsible Party (If different from patient): ------------------------------- Name Date of Birth ~Fi~rs~t----------------~M~I----~La-st--------------- SSN Home Phone ( Work Phone( Address 0.St=re=et-------------------------------------=Ci-ty--------------S~ta~te--Z=iP------- Relationsh ip to patient Emergency Contact Information: In case of emergency, whom should we notify? Relationship to patient. Phone ( May we leave message on your home phone number or cell phone number? Do you give our office permission to discuss medical information with your family members? O D If yes, please list their names and numbers below. 1. Name: Relationship Phone ( ) 2. Name: Relationship Phone ( ) If needed do you give us permission to discuss your condition with other physicians involved in your care? Signature of Patient/Responsible Party Print Name Date Receipt of tice of Privacy Practices I have received a copy of McDonnell Dermatology LLC tice of Privacy Practices. Signature of Patient/Responsible Party Print Name Date......,....fV1 ci5 oi =l-t ~; e'iid ern~iato iog-y: -LLC~ - -2569ioly;1lPia-~~,:v-e-Ste- 20~1P!-iIlta- GarciaFe ~3~~950- -- ---- 94'f-205-3376 Office Phone 941-205-337'9 Office Fax
McDonnell Dermatology Patient Name: Date: Sex Age Date of Birth Occupation/Current and or Past: Reason(s) for visit: Medications: Allergies: Pharmacy Name: Location: I. Past Medical History: Have you ever had the following: Defibrillator/Pacemaker Serious Skin Infections/HIV Bleeding Problems Thyroid Disease Diabetes High Blood Pressure Heart Attack/MI Hepatitis/Liver Disease Ulcers/GI Disease Past Surgery (please specify) Mitral Valve Prolapse Do you require antibiotics before dental work? Kidney Disease/Dialysis Asthma/Lung Disease/COPD Tuberculosis Head Aches/Seizures Current pregnant or planning pregnancy Breast Feeding Stroke/TIA/Heart Murmur Valve Replacement Artificial Joints II. SKIN HISTORY Skin Cancer Melanoma Atypical Moles Cancer (non skin) If yes, what site and year Pre-Cancers (AK's) Keloid Scars Psoriasis Eczema/Seasonal Allergies Skin Disease {Specify)
III. FAMILY MEDICAL HISTORY Melanoma Basal Cell/Squamous Cell Carcinoma - - - - Other skin diseases: Psoriasis - - Eczema - - Acne - Please list member of family with history of disease : IV. SOCIAL HISTORY Drink Alcohol Smoker Drugs YES YES YES_ NO NO NO How much in one week How much per day V. REVIEW OF SYSTEMS rmal Abnormal ( please explain) General Health Eyes Ears/se/Throat Heart Lungs Stomach/Bowel Kidneys/Urination/Prostate Arth ritis/muscles/joi nts Headaches/Seizu res Hormonal/Thyroid Problems Psychological Problems: te: This is a confidential record of your medical history and will be kept in this office. Information contained herein will not be released to any person except who you have authorized our office to release to. To the best of my knowledge, the information on this form has been correctly answered. I understand providing inaccurate information can be dangerous to my (my child's) health. It is my responsibility to inform this office of any changes in my (my child's) medical health status. I also authorize the medical staff to perform the necessary health care services that I ( my child) may need. Patient/Guardian Signature:
McDonnell Dermatology, LLC 25097 Olympia Avenue Suite 204 Punta Gorda, FL 33950 941-205-3376- Phone 941-205-3379- Fax FINANCIAL POLICY AND MEDICAL RELEASE AUTHORIZATION Date: ----- Patients who do not carry any form of medical or surgical insurance should know that all services furnished are charged directly to the patient, and that he or she is responsible for payment at the time of serve unless otherwise arranged. We will submit claims for patients with Medicare and other private insurance in which we are a preferred provider. In these cases, you are responsible for any deductibles, or co-payments at the time of service. For patients who are on any other insurance plans, payment is required at time of service. We will prepare all the necessary forms and assist you in filing claims with your carrier, so that you may be reimburse. In addition to our charge for the visit or procedure, if you have a biopsy, surgical specimen, or culture swab taken at any visit, you (or your insurance) will be billed separately by the pathologist or lab for their analysis of the specimen. We will provide your billing and insurance information to the lab or pathologist. Most misunderstanding about insurance can be avoided if you understand what your policy provides. All insurance forms processed by this office, prior to payment in full, are assigned to this practice (McDonnell Dermatology, LLC). Your cooperation in complying with the terms of this agreement will be appreciated. I authorize McDonnell Dermatology, LLC to release information from my medical records to al physicians participating in the continuity of my care. STATEMENT OF FINANCIAL RESPONSIBILITY I, the undersigned, have read the above and realize that all medical and surgical charges incurred by me or my dependents, for services rendered by McDonnell Dermatology, LLC, are my financial responsibility. All court fees, attorney fees, and or other fees necessary to collect this account should it become delinquent, are payable by me. MISSED APPOINTMENT POLICY I, the UNDERSIGNED, understand that if I miss 2 appointments without notifying the practice prior to my appointment time, I will be discharged from the practice. Patient or Parent/Guardian Signature
McDonnell Dermatology HIPPA NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT AND AUTHORIZATION The Health Insurance Portability and Accountability Act of 1996 {HIPPA} requires us to provide you with our tice of Privacy Practice which explains our privacy practices and how we may use and disclose your Protected Health Information {PHI}. In order to protect your privacy and confidentiality, we ask that you authorize when, and to whom, protected health information can be released. MAY WE LEAVE A DETAILED MESSAGE ON YOUR HOME ANWERSING MACHINE? YES NO MAY WE PHONE YOU AT WORK AND LEAVE A MESSAGE TO CALL OUR OFFICE BACK? YES NO DO WE HAVE YOUR PERMISSON TO TALK TO YOUR FAMILY MEMBERS OR OTHER INDIVIDIUALS? YES NO IF YES, PLEASE PROVIDE NAMES, PHONE NUMBER & RELATION TO YOU; Name :, Phone :, Relation :, Name: Phone :, Relation :, Name: Phone :, Relation:, ALL BENIGN TEST RESILTS ARE COMMUNICATED TO THE PATIENT THROUGH STANDARD MAIL. UNLESS OTHERWISE SPECIFIED, THESE RESULTS WILL BE SENT TO YOUR MAILING ADDRESS. THEREFORE, PLEASE NOTIFY OUR OFFICE IF YOU WANT TO RECEIVE YOUR RESULTS AT AN ALTERNATE LOCATION. By signing this form, I acknowledge that I have received a copy of McDonnell Dermatology, LLC tice of Privacy Practices and have been given an opportunity to ask questions. A copy of this consent will be included in my chart for future reference. SIGNATURE: DATE: