DERMATOLOGY CLINIC OF N MS, PLLC (662)

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DERMATOLOGY CLINIC OF N MS, PLLC (662)

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Transcription:

DERMATOLOGY CLINIC OF N MS, PLLC (662) 349-0200 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name MRN: Last First Middle Initial Mailing Address Street & Apt # City State Zip Code Home Phone Cell Phone Email Age: Birthdate: SS#: Gender: Race*: Ethnicity*: Preferred Language*: *Optional. For government purposes only. The Dermatology Clinic of N MS, PLLC does not discriminate on the basis of sex, race, ethnicity, religion, or disability. For more information, please see our Non-discrimination policy. RESPONSIBLE PARTY (if patient is a minor) Last First Middle Initial Relationship to patient: Birthdate: SS#: Gender: PATIENT S EMPLOYER Occupation: Work phone number: N/A Patient is a student or child. Is it ok to call you at work? Yes No Industry: Extension: N/A Patient is retired. RELEASE OF INFO RESTRICTIONS (Please include the person s NAME; not just the relationship) Ok to release info to the following: Ok to leave treatment info, lab results, prescription info on: Home Answering Machine Cell Voice Mail Email None Contact me only Emergency contact (not in your household): Home number: Work number: PRIMARY CARE PHYSICIAN Name: Group Name: Office Phone PREFERRED PHARMACY Pharmacy Number

DERMATOLOGY CLINIC OF N MS, PLLC (662) 349-0200 Patient: MRN: PRIMARY HEALTH INSURANCE COMPANY: Policy Number: Insured: Name Employer Relationship to patient Group Number: DOB SS# Gender SECONDARY HEALTH INSURANCE COMPANY: Policy Number: Group Number: Insured: Name DOB Employer SS# Relationship to patient Gender AUTHORIZATION TO SUBMIT INSURANCE CLAIMS I,, authorize Dermatology Clinic Of N MS, PLLC to bill my insurance company for services rendered. If necessary, copies of my medical record may be submitted with my claim. _Here NON DISCRIMINATION POLICY I,,have reviewed the non-discrimination policy of Dermatology Clinic Of N MS, PLLC. I understand that Dermatology Clinic Of N MS, PLLC complies with applicable Federal civil rights laws and does not discriminate or treat differently on the basis of race, color, national origin, age, disability, or sex. I also understand my rights to necessary language interpretation. Here HIPAA NOTICE I,, have read or received a copy of the notice of privacy protection, which outlines how Dermatology Clinic Of N MS, PLLC protects your privacy and maintains HIPAA standards. Here

FINANCIAL POLICY YOU COULD BE RESPONSIBLE FOR YOUR ENTIRE BILL!!! If you have any questions about the following policy, please ask the receptionist or manager. We want to do our best to provide the most accurate information for you. PAYMENT IS DUE AT TIME OF SERVICE: Any co-pays, co-insurances, unmet deductibles, and fees for noncovered services are due at the time of service. With many insurance companies changing their regulations, patients are now subject to a higher financial burden. That means YOU MAY HAVE TO PAY MORE MONEY OUT OF POCKET BEFORE YOUR INSURANCE COMPANY WILL PAY TOWARD YOUR MECIAL EXPENSES. We will try to make you aware of your benefits and financial responsibilities. All self-pay patients must also pay their bill in full at the time of service. NON-COMPLIANCE WITH PAYMENT: We are contractually required to collect the amount specified by your insurance company. Depending on the insurance company, we may be required to report if you refuse to pay your co-payment, coinsurance, or unmet deductible. If we are forced to report non-compliance to your insurance company, you could lose your insurance benefits. MEDICAID PATIENTS: Our office currently accepts Mississippi Medicaid and Mississippi United Health Care Community Plan. We do not accept TN Care of any kind, Magnolia, Ambetter, or any other Medicaid. If you have one of the plans we do not accept, we will not be able to treat you in our office as you must seek care from a provider contracted with your insurance company. DIVORCE AGREEMENTS: If you are bringing your child in for an appointment and your ex-spouse is obligated to you to pay for medical treatment through your divorce decree, we will try our best to accommodate your situation. HOWEVER, the parent bringing the child in for the appointment and signing this document is the one financially responsible to us. If your ex-spouse does not pay the bill, it will ultimately be your responsibility; not that of the ex-spouse. OVER PAYMENTS AND BILLING: If you overpay on your account, we will refund to you the amount you have overpaid after all services have been paid. We will bill you for any unforeseen amounts that were not collected at the time of service. Please be sure to inform us of any change in address, phone number, or employment. All balances are due in full within 14 days of the first billing date. PAST DUE AND DELINQUENT ACCOUNTS: We can notify credit bureaus, transfer your account to a collection agency, or take other collection actions against you if you do not pay your bill. You can also be terminated as a patient from our office. All attorney fees, court costs, and other expenses accumulated while collecting payment will be added to your outstanding balance. Checks that are returned will be subject to a $40 returned check fee as well as Section 97-19-57 Mississippi Code of 1972. If a patient has written us a bad check, we will be unable to accept any more checks from the patient. OUTSIDE LABS: If you have a culture taken or a growth/mole/lesion/etc removed, we will send the specimen to an independent lab for examination by a pathologist. We want to send the specimen to a lab that is in your network, BUT in-network status changes often. If you are unsure which lab we should use, please contact your insurance company. NO SHOW/SAME DAY CANCELLATIONS: In the event that you need to cancel your appointment, we ask for 24 hour notice. If you have a same-day cancellation or no-show for your appointment, you will assess a $25 fee. BY SIGNING BELOW, I HAVE READ, UNDERSTAND, AND AGREE TO THIS POLICY. ature Patient Name:

Patient Name: MEDICATION LIST of Birth: Do you currently take any medications (including topical/rub-on medications) either prescribed or over the counter: YES (list below) NO NAME OF MEDICATION DOSEAGE DOCTOR WHO PRESCRIBED Do you have any allergies: YES (list in table below) NO No know drug allergies ALLERGEN REACTION

Patient Name: Height: Weight: DOB: MRN: Do you now or have you ever had disease, condition of, or problem with the following: (Please check YES or NO) LUNGS YES NO OTHER SYSTEMIC YES NO Tuberculosis Depression COPD/Emphysema Suicide attempts Asthma Rheumatoid Arthritis CARDIOVASCULAR Diabetes Type 1 or 2? CAD Insulin Dependent? Valve replacement Kidney failure w dialysis Defibrillator Other kidney Problem: Pacemaker Hepatitis A, B, or C? PVD HIV HTN Thyroid Disease Stroke Bladder Problem: Atrial Fibrillation Prostate Cancer: On blood thinners/aspirin Stomach Problem: Cholesterol/triglycerides Inflammatory bowel SKIN YES NO Crohn s disease Intentional tanning/tanning bed Ulcerative Colitis Skin Cancer Cancer (not of skin) Type: Type if known YES NO Type: FAMILY HISTORY YES NO Organ Transplant Organ: Skin Cancer YES NO Organ: If yes, who? Joint Replacement Joint: What type if known? Joint: SOCIAL HISTORY What is/was your occupation? Are you married? Yes No SMOKING STATUS AND ALCOHOL USE Are you a smoker? No, never smoker No, former smoker Yes, current smoker If current/former smoker: smoking start date & end date Do you drink alcohol? Yes No Men: How many times in a year do you drink more than five (5) drinks in a day? Women: How many times in a year do you drink more than four (4) drinks in a day? VACCINES Have you had your flu shot? Yes No If yes, approx. date: If over 65, have you had your pneumonia shot? Yes No If yes, approx. date: FEMALES ONLY : (Please check if applicable) Currently pregnant Planning pregnancy soon Breastfeeding Irregular periods Excessive hair (face/body) On birth control; Type: Patient ature: :

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