The Dermatology & Laser Group of Irvine, A.M.C Sand Canyon Avenue, Suite 612 Irvine, CA Phone# Fax#

Transcription

1 16300 Sand Canyon Avenue, Suite 612 Irvine, CA Phone# Fax# (Please Print) Today s Date / / PATIENT INFORMATION Name Last First M.I. Maiden Name: SS# Mr. Ms. Mrs. Date of Birth / / Age Sex Marital Status: Spouse: Mailing Address Home Phone Work Phone PARENT OR RESPONSIBLE PARTY Name Mailing Address Home Phone (if different from patient) Cell Phone City State Zip What is your occupation? Last First M.I. City State Zip Work Phone Cell Phone Date of Birth / / Age Sex INSURANCE INFORMATION (Please present insurance card at time of check in.) Primary Insurance Name Ins. Address ID# Group# Secondary Insurance Name Ins. Address ID# Group# Name of Insured DOB: Name of Insured DOB: Relationship of patient to the Insured Relationship of patient to the Insured Other family members that are patients Pharmacy of choice In case of Emergency, who should be notified? Emergency contact relationship: Referred by: Primary Care Physician: Phone #: Phone Phone ALLERGIES / MEDICATIONS Are you allergic to any medications? YES NO If yes, list below: Have you ever had dental anesthesia (Novocain)? Yes No Any bad reaction? Yes No List all medications you are currently taking (including prescriptions, over-the-counter meds., vitamins, and herbals): Copy of driver s license attached. Copy of insurance card (both sides) attached. 1

2 MEDICAL HISTORY Today s Date / / Reason for today s visit: Do you have now, or have you ever had diseases or conditions of: (Please check YES or NO) Lungs: Bronchitis Emphysema Asthma Chronic Cough Morning Cough Shortness of Breath Wheezing Cardiovascular: High Blood Pressure Chest Pain Heart Attack Heart Murmur Irregular Heartbeat Phlebitis Inflammation of vein Blood clots Pacemaker YES NO YES NO Other Systemic: Diabetes Excessive thirst/hunger Amputation Thyroid Kidney Dialysis Bladder Frequency/burning Gastrointestinal Stomach absorptive disorder Nausea, vomiting, diarrhea when taking antibiotics Yeast infection when taking antibiotics Arthritis/Joint Deformity Arthralgia Limited motion Artificial joint Convulsions, Epilepsy or Seizures Fainting YES NO List any other diseases or conditions: List surgical procedures you have had in the last 6 months: Skin: Have you ever had skin cancer? YES NO Has anyone in your family had skin cancer? YES NO Do you have a history of any specific skin diseases? YES NO Do you have problems with healing? YES NO Do you develop keloids (scars) after surgery? YES NO Do you bleed easily? YES NO Do you develop skin rashes in reaction to Medications Food Environment Bandages Topical Neosporin Other Social History: Do you drink alcohol? YES NO If YES drinks per day / per week Do you use IV drugs? YES NO If YES, what? How often? Do you smoke? YES NO If YES, how much: Have you had or have you been exposed to HIV (AIDS)? YES NO (Women) Are you pregnant? YES NO Due Date: / / Hobbies? My signature below attests that all the information on my patient registration is true, accurate, correct and current as of today. Any health insurance card I present belongs to me and it attests that it represents current and valid health insurance to help pay my debt to the provider. Any false information subjects me to pay the medical debt in full and I may be subject to any State or Federal legal action for possible fraud charges. I understand that having health insurance doesn t mean that my claim will be paid and that I am responsible for appealing any denials or payments. I understand that I am responsible for ensuring my debt with the doctor is paid in full by me. Patient or Responsible Party Signature Date / / Completed by: Patient Signed by Patient Date / / Medical Assistant Doctors Signature: Date: / / 2

3 PAYMENT/FINANCIAL POLICY: (Please Print LAST, FIRST) All Patients: We follow insurance carrier s guidelines for PPO insurance plans. It is your responsibility to provide copies of current and accurate insurance information, including updates or changes in carriers or primary insured. Should you fail to provide this information, you will be financially responsible for all charges incurred. You are responsible for knowledge of your own insurance benefits and coverage (deductible, co-insurance, co-pay details, and if the doctor you re seeing is listed as participating under your insurance plan). We accept payment in the form of cash, check, or credit card. In the event that your account must be turned over to collections, you will at that time be considered a cash patient for the duration of your patient/doctor relationship payment in full will be due at the time each service is rendered. Medicare Patients: We are participating providers of the Medicare program. Patients are responsible for meeting their annual deductible and paying for the 20% co-payment. We do file with secondary /supplemental carriers. However, in the event that the secondary does not pay within 60 days, patients will be balance billed. If you have Medi-cal or a HMO as a secondary, the balance after Medicare pays is your responsibility. It is our office policy to collect at least 15% of the billed charges at the time of service if you have a MEDI-CAL, HMO, EPO or CoveredCalifornia plan as a secondary. Note: If you have recently joined (or changed) to a Medicare HMO, please let our staff know so we can update your records and advise you that you will be a cash patient. PPO or other managed care patients: You will be responsible for paying your annual deductible, co-payment, coinsurance and charges for any non-covered, cosmetic services at the time of service. MEDI-CAL, Medicare HMO, HMO's, EPO's & Covered California plans: The Dermatology & Laser Group of Irvine will not accept or bill any kind of an HMO, EPO, Medi-cal, or Covered California insurance as a primary or secondary plan. You will be considered a cash patient and the entire balance is due at the time of service. Commercial Patients: Patients who are covered by private, commercial plans in which the physician they are seeing is not a provider will be required to pay 35% of the total bill at the time of the service. The entire unpaid balance left after payment from your insurance will be billed to you regardless of the benefits and payment policies of your carrier. Your signature below signifies your understanding and willingness to comply with our payment/financial policy and authorizes payment of medical benefits to the physician C R E D I T C A R D O N F I L E O P T I O N I S V O L U N T A R Y CREDIT CARD POLICY (Please Print LAST, FIRST) This policy is perfectly compatible with all the insurance contracts, as no usual payments are asked for at the time of the visit. When the explanation of benefits comes in from your insurance(s) we will then bill you for the balance deemed owed by you the patient. If no payment is received on your account after 60 days, we will then apply your balance to your credit card. This will avoid any collection actions or fees to apply to your account. This information will be in a secure location and will not be in your chart. Our office will only use this information for collection purposes. We appreciate your understanding and cooperation. Sincerely, The Dermatology & Laser Group of Irvine MASTERCARD VISA DISCOVER Credit Card Number: Exp. Date: / Signature Code: Name as it appears on the credit card (PLEASE PRINT): Signature of Cardholder Date / / 3

4 (Please Print LAST, FIRST) AUTHORIZATION TO LEAVE MESSAGES I give my permission for the staff of The Dermatology & Laser Group of Irvine to leave messages on my telephone answering machine regarding my health care, test results, or my appointments. NOTICE OF PRIVACY PRACTICES: By signing this form, you acknowledge that you were informed of the Notice of Privacy Practices of: Dermatology & Laser Group of Irvine, A.M.C. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our Privacy Officer at I acknowledge being informed of the Notice of Privacy Practices of Dermatology & Laser Group of Irvine, A.M.C. MEDICARE PATIENTS ONLY: This office is required to keep your signature on file authorizing us to file claims to Medicare for you and to release information to that payor if they require it for the proper consideration of a claim. Please read and sign the following statement: I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. PATIENTS RESPONSIBILITY FOR CALLING RE. LABORATORY RESULTS The Dermatology & Laser Group of Irvine feels it is very important that you receive all laboratory results including blood work, cultures and pathology results. It is standard procedure for our office to notify our patients by either phone or mail of their results. However, in the unlikely event that a laboratory result is not received by our office, standard procedures for notification of our patients may not take place. We therefore ask our patients to share in the responsibility of obtaining their laboratory results by calling for results if not notified after a reasonable time period, i.e., three to four weeks for biopsy results, seven days for culture results and two weeks for routine blood work. Your physician or nurse will let you know during your visit what test will be done so you are aware of what results are pending. Your health care is our number one priority. Thank you for partnering with us in your care. PLEASE NOTE: You will receive a separate bill from an Outside Laboratory in addition to any bill you may receive from us for services rendered. Should you have any questions regarding Outside Laboratory bills you will need to call them directly at the phone number listed on their statement. Sincerely, The Dermatology & Laser Group of Irvine 4

5 (Please Print LAST, FIRST) AUTHORIZATION FOR PRACTICE TO RELEASE PROTECTED HEALTH INFO. By signing this authorization, I authorize The Dermatology & Laser Group of Irvine to use and/or disclose certain protected health information (PHI) about me to.this authorization permits The Dermatology & Laser Group of Irvine to use and/or disclose the following individually identifiable health information about me (specifically describe the information to be used or disclosed, such as date(s) of service, type of services, level of detail to be released, origin of information, etc.): The information will be used or disclosed for the following purpose: If requested by the patient, purpose may be listed as at the request of the individual. The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on. CONSENT TO MEDICAL CARE & TREATMENT OF MINOR CHILDREN I,, the natural parent/legal guardian of (LAST, FIRST NAME) the above patient authorize and consent to medical and surgical care, treatment and procedures to be performed for my child by a licensed physician/provider. In the sole discretion of the attending physician/provider, such care, treatment and procedures are necessary or advisable in the interest of my child s health and well-being. This consent is valid until I have notified The Dermatology & Laser Group of Irvine that this policy has been revoked FOR OFFICE USE ONLY INABILITY TO OBTAIN ACKNOWLEDGEMENT To be completed only if no signature is obtained. If it is not possible to obtain the individual s acknowledgement, describe the good faith efforts made to obtain the individual s acknowledgement, and the reason why the acknowledgement was not obtained: - Signature of provider representative Date / / ( ) Individual refused to sign ( ) Communication barriers prohibited obtaining the acknowledgement ( ) An emergency situation prevented us from obtaining acknowledgement ( ) Other (Please Specify) 5

6 LINDA M. GLOBERMAN, M.D. JEFFREY K. LANDER, M.D. The Dermatology & Laser Group of Irvine, A.M.C Sand Canyon Ave., Suite 612 Irvine, CA (949) fax (949) Dermlaserirvine.com MARY T. von HOFFMANN, M.D. REFERRAL LETTER: If you were referred to our office by another physician please provide their information so we can relay your essential findings to them. Referring Physician Name: Address: Phone No.: Patient Name Age: Date: Dear, Thank you for referring your patient. The following is a summary of essential findings. Sincerely, 6