Welcome. Carlos Paz, M.D., Ph.D. Dear Patient,

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1 Welcome Dear Patient, We are delighted to welcome you to Fresno Dermatology Specialists, the office of Dr. Carlos Paz. This letter contains answers to some of the most commonly asked questions by patients entering our office. Fresno Dermatology Specialists is located in the Meridian Professional Center on Chestnut Avenue. We are a full service dermatology practice providing medical, cosmetic, and surgical services to patients of all ages. Our hours are Monday through Friday from 8:00am to 6:00pm and Saturday from 8:00am to 1:00pm. All new patients are asked to complete the Patient Registration, Financial Policy, Notice of Privacy Practices and Health History in full and provide them to the receptionist when checking in for your initial appointment. If you find that you are unable to keep your appointment, please contact our office 24 hours prior to your scheduled time. For the benefit of our patients, we are contracted with several insurance carriers. You will want to check with your insurance company to find out if we are listed as providers within your particular network. As part of our contact with your insurance carrier, we are required to collect any co-pay(s) from you at the time of service. Please come prepared with your co-pay, identification card, and insurance card. If you have any questions or concerns, please call our office at We look forward to meeting you soon! Sincerely, Dr. Carlos Paz & Staff of Fresno Dermatology Specialists 1

2 Patient Registration Name: First Middle Last Jr. Sr. Prefer to be called: Sex: M F Widowed Married Divorced Single Address: Street# Street Name Apt.# City State Zip Code Employer: Name Address Home Phone: Date of Birth: / / Age: Month Day Year Work Phone: Cell Phone: Social Security #: Insurance Policy Owner s S.S.# Primary Insurance: Subscriber ID: Group #: Secondary Insurance: Subscriber ID: Group #: Where should the statement of your account be sent if different from above? Name Address Apt# State Zip Primary Doctor: Phone: Who referred you? How did you hear about our office? Circle or explain: Google Yelp.com Healthgrades.com YP.com Yellow Pages Magazine Ad Family/Friend Other In case of emergency contact: Phone: Relationship: Your To establish optimal relations with our patients and avoid misunderstanding regarding our payment policies, our staff is trained to inform you of the financial policies of this office. Payment is expected from you at the time of the service, for your part of the charges. We accept all major credit cards for your convenience. Your signature below indicates that you understand and accept this policy. Further, your signature authorizes the Doctor to release such medical information necessary to process your insurance claims (if any). You herein authorize payment of medical benefits to the Doctor when an assignment claim is filed. It is the policy of this office that the adult presenting the child for treatment is responsible for payment of the patient portion at the time of service. Signature of patient or legal guardian Name of Policy owner if other than patient Date 2

3 Financial Policy Insurance Billing: Fresno Dermatology Specialists will submit claims to your insurance carrier (primary and secondary) either as a courtesy to the patient/subscriber or as mandated by law. In order to do so we will request you to provide us with the following information: Your written authorization to submit claims and release any medical information deemed necessary by your insurance carrier to process claims (authorization included on our Patient Registration Form). Verification of insurance coverage. If Fresno Dermatology Specialists will be billing insurance, we will require you to submit your insurance card at the time of service. o If we do not receive a copy of your insurance card your account will be established as a self-pay. Assignment of benefits (authorization is included on our Patient Registration Form). Timely notification and verification of any change in coverage or carriers. Unless mandated by law or other contractual agreements, we bill insurance as a courtesy. Due to the number of plans and coverage options; we cannot provide individual policy benefits information. We are contracted with several insurance carriers but may not be contracted with your individual plan or group. You will need to contact your carrier directly to determine if we are contracted with them and on your network. Only medically necessary procedures will be billed to the insurance carrier. Your co-pay and any applicable deductible are due at the time of service. Your insurance carrier will not be billed for elective, cosmetic and other non-covered services. Payment for these services will be collected at the time of service. We accept cash, local checks, debit cards and all major credit cards. Outside Services: To provide the best care possible, Fresno Dermatology Specialists may, on occasion, send specimens to an outside source for processing. Examples of these services are pathology and laboratory testing. Should we send specimens to other providers you will receive a separate billing statement from the outside pathologist and/or laboratory; these charges will be in addition to those for services rendered by Fresno Dermatology Specialists. Cosmetic Procedures: Elective cosmetic procedures are not covered by insurance companies. You are financially responsible for all charges associated with elective, cosmetic and non-covered services. These services and/or procedures are payable in full at the time of service. Prior to some cosmetic treatment(s) we request that you make an appointment with our office for a cosmetic consultation. 3

4 Financial Policy Con t. TEL FAX Appointment Cancellations: The providers make every effort to see you at your appointment time; we ask that you make every effort to arrive on schedule. We understand that occasionally it will be necessary to cancel an appointment. As a courtesy, we ask that you provide a twenty-four hour notice. Gift Certificates: Fresno Dermatology Specialists offers Gift Certificates for services and products. They are available in amounts from $ , in $100 increments, and are not redeemable for cash. Gift Certificates are issued to a specific person. For tracking purposes, a patient/client account will be established for the gift card recipient (if not already set-up) at the time a Gift Certificate is purchased. Late Charges and Other Fees: Accounts with balances over 90 days old are subject to late fees. Accounts referred to a collection agency may be subject to a $50.00 collection fee, attorney fees, and/or the percentage allowed under California state law. There is a $35.00 fee for all checks returned for NSF (non-sufficient funds). Patient Signature Date: Parent/Guardian signature required for minor (less than 18 years of age) Relation to patient other that self (circle): Parent Guardian Printed Patient Name: Date of Birth: ing List: Do you wish to be added to our list for events and promotions? YES NO 4

5 Notice of Privacy Practices / Patient Consent Form www fdsderm com 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 the 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 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 Private 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. DO WE HAVE YOUR PERMISSION TO: LEAVE A MESSAGE/APPOINTMENT REMINDER ON YOUR ANSWERING MACHINE AT HOME? LEAVE A MESSAGE/APPOINTMENT REMINDER ON YOUR PLACE OF EMPLOYEMENT? LEAVE A VOICE MESSAGE/APPOINTMENT REMINDER ON YOUR CELLULAR PHONE? LEAVE A TEXT MESSAGE/APPOINTMENT REMINDER ON YOUR CELLULAR PHONE? DISCUSS YOUR MEDICAL CONDITION WITH ANY OTHER MEMBER OF YOUR HOUSEHOLD? IF YES, WHOM: RELATIONSHIP: Please provide any additional comments in reference to the release of your medical condition(s) or appointments This Consent was signed by: Printed Name Patient or Relative Relationship to Patient (if other than patient) Signature / / Date 5

6 Dermatology Medical History 7025 N. Chestnut Ave Suite 105 Fresno, CA Patient: Date: / / Reason for today s visit: Past Medical History: (Circle all that apply) Anxiety Arthritis Artificial joints Asthma Atrial fibrillation BPH (Benign Prostatic Hyperplasia) Bone Marrow Transplantation Breast Cancer Colon Cancer COPD (Emphysema) Other Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD (Acid reflux) Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement Past Surgical History: (Circle all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Coronary Artery Bypass PTCA Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed (Right, Left, Bilateral) Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Other 6

7 Dermatology Medical History Con t. TEL FAX Skin Disease History: (Circle all that apply) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Other Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Do you wear sunscreen? YES NO If yes, what SPF? Do you tan in tanning salon? YES NO Do you have a family history of Melanoma? YES NO If yes, which relative(s) Any other family history? List all medications you are currently taking (including prescriptions, over-the-counter meds, ect) Are you allergic to any medications? YES NO if yes, list below: Social History: (Please circle one) Cigarette Smoking Never smoked Quit: former smoker Smokes less than daily Smokes daily Alcohol Use: YES NO Language: English Spanish Other: Race: White Black/African American Asian American or Native Alaskan Native Hawaiian/Pacific Islander How often do you exercise? Once a day A few times a week A few times a month Never Ethnicity: Hispanic/Latino Non-Hispanic/Latino What is your caffeine use? Once a day A few times a week A few times a month Never 7

8 Dermatology Medical History Con t. Review of Systems: (Circle all that apply) Problems with bleeding Problems with healing Problems with scarring Rash Immunosuppression Hay fever Chest pain Fever or chills Night sweats Unintentional weight loss Thyroid problems Sore throat Blurry vision Abdominal pain Bloody stool Bloody urine Joint aches Muscle weakness Neck stiffness Headaches Seizures Cough Shortness of breath Wheezing Anxiety Depression Alerts: (Circle all that apply) Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotic ointments Artificial heart valve Artificial joints within past 2 year Blood thinners Defibrillator MRSA Pacemaker Premedication prior to procedures Rapid heart beat with epinephrine Pregnancy or planning a pregnancy Pharmacy Name: Street: Zip code: Occupation/Workplace 8