Cardiologist: Phone: Family Physician: Phone: Pharmacy: Phone:
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- Tamsin Tucker
- 7 years ago
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1 Patient : Date of Birth: Premier Dermatology & Cosmetic Surgery Information Sheet Cardiologist: _ Phone: Family Physician: Phone: Pharmacy: Phone: Medications: please list all medications that you are taking and what condition you are taking them for) On the appropriate line, list why you are taking this medication Allergies: please list all drug, anesthetic (numbing medication), tape, latex, iodine or food allergy of Allergy Briefly describe the reaction to your allergy Chief Complaint: (Please briefly describe why you are here today and list the names of any medications that you have tried for your complaint) Personal Medical History: (Please answer the following questions) If you have ever been diagnosed with skin cancer, please list the type, location and year: Have you ever been diagnosed with cancer? If yes, where and what year? Do you currently smoke? Have you ever smoked? If yes, how many pack(s) per day? How many year have you smoked? Do you drink? If yes, alcohol type? Frequency? Last drink? Are you sexually active? (check one) Yes No Previously Are you currently pregnant, possibly pregnant or planning pregnancy? Family Medical History: Please list family member (mother, father, brother, sister, cousin etc.), no names, that have the following condition: asthma, hayfever, psoriasis, eczema, dermatitis, or something similar to your present condition Do you have a family history of Skin Cancer? If yes, who and what type: Do you have a family history of Malignant Melanoma? If yes, who? (OVER)
2 Please check all that apply or ever have applied to you in each system: Cardiovascular: Heart Attack Congestive Heart Deep Vein High Blood Pressure High cholesterol (Myocardial infarction) Failure Thrombosis (hypertension) (hyperlipidemia) Coronary Artery Chest Pain ( ) Pacemaker Defibrillator Disease (angina) Stent (Year: ) Heart Surgery Heart Murmur Heart Valve Replacement Coumadin Asprin Plavix Other: Gastrointestinal: Appendix Removed Gallbladder Removed Crohn s disease Diverticulitis Acid Reflux (Appendectomy) (Cholecystectomy) (Gastroesophageal reflux disease) Pancreatitis Cirrhosis Ulcerative Cholitis Irritable Bowel Disease Hernia ( ) Hepatitis ( ) Other: Musculoskeletal: Fibromyalgia Muscular Dystrophy Osteoarthritis Osteoporosis Rheumatoid Arthritis Arthritis Joint Replacement: Location When Other: Genetic Syndrome: Down s Autism Cystic Fibrosis Other: Head, eyes, ears, nose and throat (HEENT): Cataracts Glaucoma Deafness Retinal Detachment Other: Hematologic: Anemia Bleeding Disorder Hemophilia Hodgkin s Disease Sickle Cell Anemia Other: Genitourinary: Kidney Stones Urinary Incontinence Kidney removed Kidney failure Enlarged Prostate Other: Neurologic: Dementia Migraine/Headaches Parkinsons Seizure Disorder Multiple Sclerosis Strokes (Cerebrovascular Accident) Mini-Strokes [TIA s] Other: (Transient Ischemic Attack) Pulmonary: Asthma COPD Emphysema Pneumonia Pulmonary Embolism Sleep Apnea Other: Psychiatric: ADD ADHD Anxiety Depression Bipolar Other: Metabolic/Endocrine: Diabetes ( ) Hyperthyroidism Hypothyroidism Other: Immunologic: HIV Sarcoidosis Lupus Other: Infectious Disease: Tuberculosis Lyme Disease Shingles (Herpes Zoster) Cold Sores (HSV-1) History of MRSA Other: Signature: Date:
3 PREMIER DERMATOLOGY & COSMETIC SURGERY PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION With my consent, PREMIER DERMATOLOGY & COSMETIC SURGERY, may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to PREMIER DERMATOLOGY & COSMETIC SURGERY, Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. PREMIER DERMATOLOGY & COSMETIC SURGERY, reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to PREMIER DERMATOLOGY & COSMETIC SURGERY, Privacy Officer at 537 Stanton-Christiana Road, Newark, DE With my consent, PREMIER DERMATOLOGY & COSMETIC SURGERY, may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others. With my consent, PREMIER DERMATOLOGY & COSMETIC SURGERY, may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With my consent, PREMIER DERMATOLOGY & COSMETIC SURGERY, may to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that the practice restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to PREMIER DERMATOLOGY & COSMETIC SURGERY, use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, PREMIER DERMATOLOGY & COSMETIC SURGERY, may decline to provide treatment to me. I,, hereby grant my permission for PREMIER DERMATOLOGY & COSMETIC SURGERY to inform the following individual/individuals of any and all results pertaining to my medical history and/or care: Signature of Patient or Legal Guardian Patient s Date Print of Patient or Legal Guardian
4 CONSENT FOR TREATMENT A. I hereby request evaluation and treatment by a provider (physician, PA, or NP) of PREMIER DERMATOLOGY & COSMETIC SURGERY and/or their staff. B. I authorize payment of medical benefits for myself/dependent directly to PREMIER DERMATOLOGY & COSMETIC SURGERY for professional services. C. For all services rendered to minor patients, the adult accompanying the patient is responsible for any payment due at the time of service. D. I authorize the release of medical information necessary to process insurance claims. X (Signature of patient OR Responsible Party if a Minor) (Date) FOR MEDICARE PATIENTS ONLY: Please sign below once or twice as applicable. You may complete insurance information or give cards to the receptionist to complete. I request that payment of authorized Medicare and/or insurance benefits be made either to me or on my behalf to PREMIER DERMATOLOGY & COSMETIC SURGERY for any services furnished me by said physician. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine the benefits payable for related services. X_ (SIGNATURE OF BENEFICIARY) (HIC CLAIM NUMBER) (DATE) SECONDARY INSURANCE FOR MEDICARE PATIENTS I request that payment of authorized Medigap benefits be made either to me or on my behalf to PREMIER DERMATOLOGY & COSMETIC SURGERY. I authorize any holder of medical information about me to release to (below named Medigap insurer) any information needed to determine the benefits payable for related services. X (SIGNATURE OF BENEFICIARY) (MEDIGAP CARRIER) (MEDIGAP ADDRESS) (MEDIGAP POLICY NUMBER) (MEDIGAP POLICY HOLDER)
5 PDCS FINANCIAL AGREEMENT and MISSED APPOINTMENT POLICY Thank you for choosing PREMIER DERMATOLOGY & COSMETIC SURGERY for your family s dermatologic and cosmetic surgical needs. We are pleased to welcome you to our practice. Our chief concern is that you and your family receive the finest care. We understand that occasionally some of our patients will experience financial difficulties. It is our hope that you will bring these situations to the attention of our Billing Department to allow us to help you manage your account in the most effective manner. Please be advised that your insurance coverage is determined by a contract between you and your insurance company. We will be glad to submit your claims for payment; however, the final responsibility for payment for services rendered rests with you, the patient, or the guarantor (person with financial responsibility for the account). Our financial policy is as follows. Please feel free to discuss this with our Billing Department at any time. Please complete all insurance information, read our financial policy below, and sign below to verify your receipt and understanding of this information. 1. We accept cash, check, Visa, and MasterCard. 2. If Medicare is your primary insurance, and your visit is for a medical condition that is generally covered or expected to be covered, we will gladly submit your insurance claim to Medicare. You will be responsible for any co-insurance and/or deductible, as required by Medicare. 3. For all insurances, your co-payment, co-insurance, and self-payment amounts are due upon receipt of our bill. For office visit copays, you are required by your insurance contract to pay at the time of service. 4. If your insurance carrier requires a referral from your primary care provider for treatment, it is your responsibility to obtain the referral prior to your appointment. If you do not obtain and provide the referral within the time allowed by your insurance carrier, you will be financially responsible for all services rendered. 5. Returned checks are subject to a $30.00 service charge. 6. We are happy to provide any counseling on our billing practices; however, if your account is not paid within 90 days of the date of service, you will be responsible for full payment plus a monthly finance charge of 1.5% per month. 7. If we are participating with your insurance company, we are contractually required to adjust your account by a certain amount which is known as a contractual write-off. This does not mean you will not have a balance. We will bill you for balances as intended and directed by your insurance company. 8. If your account goes into collection, then in addition to your outstanding balance, you will be responsible to pay a 25% fee charged by the collection agency as well as any subsequent legal or court costs. 9. Any Medical Necessity forms or letters required by your insurance company, or any communication outside the usual and customary forms required for billing or communication with other providers will be subject to a $25.00 administrative fee. 10. We will be happy to complete your disability forms which are subject to a $25.00 administrative fee. 11. As a courtesy to our patients relocating out of the area or changing providers for any other reason, we will be happy to supply you or your new provider with a copy of your medical records at no charge. Any other requests for copies of medical records will be subject to a $25.00 administrative fee. This does not apply to necessary ongoing communication with your other providers, related to your ongoing care. Request for MEDICAL RECORD COPIES will take a minimum of 3 full business days to process. 12. I authorize payment of medical benefits for myself/dependents directly to PREMIER DERMATOLOGY & COSMETIC SURGERY for professional services. 13. I authorize the release of medical information necessary to process insurance claims. 14. We require 24 hour notice of cancellation of your appointment. Missed appointments or cancellations with less than 24 hours notice will be subject to a $30.00 missed appointment fee. 15. If a patient no shows or cancels with less than 24 hours notice, 3 times within a 12 month time period, his or her provider may terminate the patient-provider relationship. Likewise, the patient will not be seen by another PDCS provider, but will be asked to seek care elsewhere. 16. If a patient has cancelled or no showed a surgical procedure, then we may require a deposit to reschedule the appointment. This deposit will be between $100 and $1,000, depending on the time allotted for the appointment. This deposit will be forfeited, if another cancellation or no show occurs. X PATIENT, GUARANTOR, OR PERSONAL REPRESENTATIVE S SIGNATURE DATE MRN Your signature on this page signifies that you acknowledge and accept the above information. This also serves as an assignment of insurance benefits to be paid directly to: PREMIER DERMATOLOGY & COSMETIC SURGERY. S:\Forms\PDCS Financial Agreement and Missed Appointment Policy.doc 04/22/2014
6 APEX MEDICAL CENTER 537 STANTON-CHRISTIANA ROAD, SUITE 107/207 NEWARK, DE TELEPHONE: (302) FAX: (302) Receipt of Notice of Privacy Practices Written Acknowledgement Form I am a patient of Premier Dermatology & Cosmetic Surgery. I hereby acknowledge receipt of Premier Dermatology & Cosmetic Surgery s Notice of Privacy Practices. [please print]: Signature: Date: OR I am a parent or legal guardian of [patient name]. I hereby acknowledge receipt of Premier Dermatology & Cosmetic Surgery s Notice of Privacy Practices with respect to the patient. [please print]: to Patient: Parent Legal Guardian Signature: Date: I,, hereby grant my permission for PREMIER DERMATOLOGY & COSMETIC SURGERY to inform the following individual/individuals of any and all results pertaining to my medical history and/or care: Signature of Patient or Legal Guardian Patient s Date Print of Patient or Legal Guardian S:\HIPAA\Receipt of Notice of Privacy Practices Written Acknowledgement Form docx
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