Race: Caucasian American Indian or Alaska Native Asian African American Native Hawaiian or Other Pacific Islander

Transcription

1 NORTH DALLAS DERMATOLOGY ASSOCIATES DEMOGRAPHIC INFORMATION EMA INTAKE FORM PAGE 1 NAME: Female Male DOB: / / Age: Last First Race: Caucasian American Indian or Alaska Native Asian African American Native Hawaiian or Other Pacific Islander Other Ethnicity: Hispanic or Latino Not Hispanic or Latino Your visit today may include labs, cultures and/or skin biopsies. We generally receive results of lab work/cultures in approximately 3-5 days and skin biopsy results in 7-10 days. We will call you with results and any additional information prescribed by your physician. For BENIGN / NEGATIVE results on any tests listed above: YES, you may leave a detailed message informing me of my results at the following telephone #: NO, do not leave a detailed message. Please leave call back information only on my voic . Who is your Primary Care Physician? NAME: Phone #: Did a physician refer you to our clinic? Yes No If yes, Dr. If a physician did not refer you, how did you find our clinic? PHARMACY NAME PHONE ADDRESS CHIEF COMPLAINT (Reason for your visit) MEDICAL INFORMATION PLEASE CHECK ANY CONDITIONS THAT CURRENTLY APPLY TO YOU: OR None Apply To Me Anxiety Colon Cancer Hepatitis, Type: Lymphoma Arthritis COPD Hypertension(high blood pressure) Prostate Cancer Asthma Coronary Artery Disease HIV/AIDS Seizures Atrial Fibrillation Depression Hypercholesterolemia Stroke Bone Marrow Transplant Diabetes Hyperthyroidism OTHER BPH(benign enlargement of the prostate) End Stage Renal Disease Hypothyroidism Breast Cancer GERD Leukemia Bleeding Tendency Hearing Loss Lung Cancer PAST MEDICAL HISTORY: (past illnesses/surgeries) PAST SURGICAL HISTORY Appendix (Appendectomy) Heart : Coronary Artery Bypass Surgery Ovaries (Oophorectomy) : Endometriosis Bladder (Cystectomy) Heart : PTCA Ovaries (Oophorectomy) : Cysts Breast : Mastectomy Heart : Mechanical Valve Replacement Ovaries (Oophorectomy) : Cancer Right Left Both Heart : Biological Valve Replacement Prostate(Prostatectomy) : Prostate Cancer Breast: Lumpectomy Heart : Transplant Prostate(Prostatectomy) : Prostate Biopsy Right Left Both Joint Replacement - Knee Prostate (Prostatectomy) : TURP Breast Biopsy Right Left Both Skin : Skin Biopsy Breast Reduction Joint Replacement - Hip Skin : Basal Cell Carcinoma Breast Implants Right Left Both Skin : Squamous Cell Carcinoma Colon Cancer Resection Kidney : Biopsy Skin : Melanoma Colon : Diverticulitis Kidney : Nephrectomy Spleen (Splenectomy) Colon : Inflammatory Bowel Disease Kidney : Kidney Stone Removal Testicles (Orchiectomy) Gallbladder (Cholecystectomy) Kidney: Transplant Uterus (Hysterectomy) : Fibroids Uterus (Hysterectomy) : Uterine Cancer OTHER OVER

2 PAGE 2 SKIN DISEASE HISTORY Acne Dry Skin Hay fever/allergies Psoriasis Actinic Keratosis Eczema Poison Ivy Blistering Sunburns Flaking or Itchy Scalp Precancerous Moles Personal History of Skin Cancer Personal History of Sun Exposure Family History of Skin Cancer Basal Cell Carcinoma Do you wear sunscreen daily? Yes No Basal Cell Carcinoma Squamous Cell Carcinoma If yes, what SPF? Squamous Cell Carcinoma Melanoma Do you tan in a tanning salon? Yes No Melanoma Unsure Multiple blistering sunburns as a child? Yes No Skin Cancer, unsure which type No History of Skin Cancer History of atypical moles? Yes No No Family History of Skin Cancer LIST ALL CURRENT MEDICATIONS SKIN HISTORY MEDICATION HISTORY ALLERGIES LIST ALL ALLERGIES TO PRESCRIPTION AND NON-PRESCIPTION MEDICINES SOCIAL HISTORY Never Drink Alcohol less than 1 drink per day 1-2 drinks per day 3+ drinks per day Never Smoked Quit, Former Smoker Smokes Less Than Daily Smokes Daily

3 PATIENT REGISTRATION : Patient Name: of Birth: Marital Status: First Last Address: City: State: Zip: Street/Apt #/PO Box *Preferred Phone#: Home( ) Cell( ) Work( ) Is it OK to leave a detailed message? Yes No Home #: Cell #: Work #: Sex: F M SSN: Preferred Language: Race: White Black/African American Asian American Indian Hawaiian/Pacific Islander Other Ethnicity: Hispanic Non-Hispanic/Non-Latino Other/Non-determined Referred by: *Physician( ) *Patient to Patient( ) *Family( ) Insurance( ) Internet( ) Other( ) *Please give Name/Address: Employer: Occupation: Preferred Pharmacy: Pharmacy Phone: Pharmacy Address: : City: State: Zip: Emergency Contact: Name: Relationship to Patient: Home #: Cell #: Work #: Person Responsible for Payment (If different from above): Name: Relationship to Patient: Address: City: State: Zip: Street/Apt #/PO Box Home #: Cell #: Work #: SSN#: of Birth: Primary Insurance Information: **Please present your ID & Insurance Cards at every visit** Insurance Co.: Phone #: Name of Insured: of Birth: Relationship to Patient: Policy #: Group #: Secondary Insurance Information: Insurance Co.: Phone #: Name of Insured: of Birth: Relationship to Patient: Policy #: Group #:

4 Procedure Price List Welcome to North Dallas Dermatology Associates. We are honored to be a part of your healthcare team. *Please note that you may disregard this notice if you are a Medicare recipient. Many dermatology procedures go towards your deductible. Please be aware that if you have one of these procedures done, we collect an estimated payment on a few of these procedures at the time of check out. Should your insurance pay these procedures in full, we will refund your payment upon receipt of your insurance payment. For your convenience and because we know that no one likes a surprise, we have listed below the most common procedures done in this office which normally go towards your deductible. Biopsy of a skin lesion o One lesion $ st $30.00 each additional Destruction of actinic keratosis/precancerous lesions $75.00-$ Destruction of a wart, molluscum, or other benign lesion $ $ Excision of a skin lesion on the trunk, genitalia, arms and legs $90.00-$ Excision of skin lesion on the scalp, neck, hands and feet $90.00-$ Excision of skin lesion face, ears, eyes, nose and lips $98.00-$ Surgical repair of the above listed skin lesion(s) $ $ Name of Patient Signature of Patient or Responsible Party of Birth

5 Authorization for Use and Disclosure of Protected Health Information I hereby authorize North Dallas Dermatology Associates to use and/or disclose my protected health information as described below to: Name and relationship to recipient(s): For the following purposes: (describe each purpose of use/disclosure If disclosing different types of information below for different purposes, the authorization must specify the purpose for which each type of information is being disclosed.) I understand that: 1) THIS AUTHORIZATION IS VOLUNTARY AND I MAY REFUSE TO SIGN THIS AUTHORIZATION WITHOUT AFFECTING MY HEALTH CARE OR THE PAYMENT FOR MY HEALTH CARE 2) I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used and/or disclosed under this authorization (if allowed by state and federal law. See 45 CFR ). 3) I may revoke this authorization at any time by notifying North Dallas dermatology Associates in writing as set forth in the Notice of Privacy Practices. However, it will not affect any actions taken before the revocation was received or actions taken in reliance thereon, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer with the right to contest a claim under the policy. 4) North Dallas Dermatology Associates agrees to maintain the confidentiality of my protected health information; however, if the person or organization authorized to receive the information is not a health plan, health care clearinghouse or health care provider, federal law (HIPAA) requires me to be advised that information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by HIPAA rules. Marketing: If this box has been checked by the practice, I understand that the practice will receive compensation for using or disclosing my information for marketing purposes. Type of information to be disclosed: Entire Medical Record Most Recent 5 Year History Radiology Reports Office Chart Notes All Hospital Records Operative Reports Billing Statements Transcribed Hospital Reports Other: Dental records History and Physical Exam Laboratory Reports Emergency and Urgent Care Records Pathology reports Medical Records for Continuity of Care Consultation Diagnostic Imaging Reports Discharge Summary Emergency Room Reports In addition, I authorize that this will include health information relating to (check if applicable): HIV/AIDS infection Drug/Alcohol abuse Genetic Testing Patient Name: Patient ID #: Signature of Patient or Legal Representative (if applicable) Printed Name of Patient s Representative (If applicable) Relationship to Patient (If applicable) Parent or guardian of unemancipated minor Court appointed guardian Executor or administrator of decedent s estate Power of Attorney Signature of Witness

6 Acknowledgement of Receipt of Notice of Privacy Practices Patient Name: Patient DOB: I hereby acknowledge that I have received a copy of North Dallas dermatology Associates Notice of Privacy Practices. I understand that I have the right to refuse to sign this acknowledgement if is so choose. Signature of Patient or Legal Representative (if applicable) Printed Name of Patient s Representative (If applicable) Relationship to Patient (If applicable) Parent or guardian of unemancipated minor Court appointed guardian Executor or administrator of decedent s estate Power of Attorney FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices on the following date, but acknowledgment could not be obtained because: Patient/representative refused to sign Emergency situation prevented us from obtaining acknowledgment at this time (Will attempt again at a later date) Communication barriers prohibited obtaining acknowledgment (Explain) Other (Specify)

7 Financial Policy Thank you for selecting our practice for your dermatological needs. Our goal is to provide you with the highest quality of treatment and service. Your complete understanding of your financial responsibilities is an essential element of your care. If you have any questions about the following policy, please do not hesitate to ask our staff. Patients are responsible for payment at the time of service. However we do accept Cash, Checks, MasterCard, Visa, Discover and Care Credit. We DO NOT accept AMEX. We are contracted providers with many insurance plans and will accept assignment of benefits. As a courtesy, we will file all claims, including secondary insurance, to the plans with which we participate. Please inform us of any special requirements in your plan. You are responsible to pay for any co-payments, applicable dermatology procedures, Levulan (if applicable) or cosmetic treatments at the time of each visit. Many dermatology procedures go toward your deductible. Please be aware that we collect an estimated payment on a few of these procedures at the time of check out (please refer to our Procedure Price List for details). Should your insurance pay these procedures in full, we will refund your payment upon receipt of your insurance payment. You are required to pay the deductible or co-insurance amounts designated by your insurance company. If your insurance company denies your bill, you will be billed directly for those services and are held financially responsible. In the event your health plan determines a service to be not covered, or you do not have an authorization, you will be responsible for the complete charge. We encourage our patients to understand their policy and to contact their plan for clarification of benefits prior to services being rendered. In addition, if you have coverage with an insurance plan that we do not contract with, we will prepare a receipt for you at the time of service with all the necessary information needed for you to file the claim. All charges for your care and treatment are due at the time of service for these health plans. You must inform the office of all insurance changes, authorization referral requirements, and address changes. In the event the office is not informed before care is rendered, you will be responsible for any charges that are denied. In cases of divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those charges. If the divorce decree requires the other parent to pay all or part of the costs, it is the authorizing parent s responsibility to collect from the other parent. You may receive a separate bill for laboratory or pathology services from an off-site lab for any tests your physician may order. Please discuss any billing errors or discrepancies with that laboratory. Other Miscellaneous Fees Cancellation, Missed Appointments and Late Arrivals Returned Check Fee Collection Fee If you need to cancel an appointment, we kindly request that you allow at least 24-hour notice so that your appointment may be given to another patient who may be in need of urgent care. If we do not receive 24-hour notice there will be a $30.00 cancellation fee billed. Patients with multiple cancellations or missed appointments also may be discharged from our practice. In an event you are running late, please call our office. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule. There will be a $30.00 charge for all returned checks. If your account is turned over to our collection agency, you will be responsible for the collection fee charged to us by the agency in addition to your outstanding balance I have read and understand the financial policy, and I agree to be bound by its terms. I understand and agree that such terms may be amended in the future by the practice. Signature of Patient or Responsible Party Printed Name of Patient of Birth

8 Optional Credit Card Save on File For your convenience and as an option, we kindly request that you leave a credit card on file which may be used to reduce your remaining balance after insurance pays. Please complete and sign the following: Credit Card Authorization Initials Initials Initials I authorize North Dallas Dermatology Associates to bill my insurance for the services rendered today. Upon receipt of payment from my insurance company, I authorize North Dallas Dermatology Associates to charge the below listed credit card in the amount of the remaining unpaid balance. I understand that cosmetic procedures are not billed to my insurance. Should there be a remaining balance on cosmetic services, I authorize North Dallas Dermatology Associates to charge the below listed credit card in the amount of the remaining unpaid balance. An will be sent to notify me of the additional charge to my credit card. Patient Name Patients of Birth Credit Card Billing Address: Address line 1 Address line 2 City, state, zip code Card holders address Best number to be reached Name as it appears on credit card Last four numbers on credit card Credit card expiration date Credit card holder authorizing signature OFFICE USE ONLY: Employee initials: saved/ Sent to PAS:

9 NAME DATE PLEASE CHECK YES OR NO IN THE BOX PROVIDED FOR ALL SYMPTOMS YOU ARE CURRENTLY EXPERIENCING Hematologic/Lymphatic Problems with bleeding Swollen glands Tender glands Anemia Transfusion Integumentary - Skin Endocrine No to All Gastrointestinal Thyroid problems Nausea or vomitting Excessive thirst Heartburn Eyes No to All Increasing constipation Redness Persistant diarrhea Pain Blood in stool or black stool No to All Double vision Tightness or abdominal pain Problems with healing Blurred vision Jaundice Problems with scarring Easy bruising Ears/Nose/Mouth/Throat No to All Genitourinary Redness Ringing in ears Pain/burning on urination Rash Runny nose Blood in urine/cloudy, Hives Sores in mouth Smoky urine Itching Dryness in mouth Discharge from penis/vagina Sun sensitive Frequent sore throat Getting up at night to pass urine Tightness Difficulty swallowing Vaginal dryness Nodules/bumps Hoarseness Rash/ulcers in genital area Hair loss Color changes - hands/feet Allergic/Immunologic No to All Cardiovascular No to All Musculoskeletal No to All Frequent sneezing Sudden onset chest pain Morning stiffness Susceptibilty to infection Sudden changes of heart beat Joint pain Immunosuppression High blood pressure Muscle weakness Hay fever Swollen legs or feet Muscle tenderness Joint swelling Constitutional No to All Respiratory No to All Neuroligical/Psychiatric No to All Fever, chills or shakes Cough Headaches Night sweats Shortness of breath Dizziness Unintentional weight gain Wheezing Fainting Unintentional weight loss Anxiety Depression Agitation ALERTS ALERTS ALERTS Allergy to: Artificial Heart Valve Pacemaker Adhesive Artificial joints within 2 years MRSA/Staph Lidocaine Blood Thinners Premedication Prior to Procedures Topical Antibiotic Ointments Defibrillator Rapid Heartbeat with Epinephrine Are you pregnant? No to All REVIEW OF SYSTEMS AND ALERTS PREGNANCY AND CHILDBEARING INFORMATION FOR WOMEN ONLY Planning on becoming pregnant soon? No to All No to All Are you breastfeeding? Are you on some form of birth control? If yes, what form?