Welcome to Soderma, Dermatology. We are a comprehensive dermatology practice, providing a full range of medical, surgical and cosmetic dermatologic services for all skin types. Whether it is treating skin cancer, clearing acne, removing fine lines and wrinkles, or refining uneven skin complexions, our board certified dermatologists, Dr. Cylburn E. Soden, Sr. and Dr. Cylburn E. Soden, Jr. work individually with each patient to design a personalized treatment plan to help you look and feel your best. At Soderma our entire staff is passionate about providing excellent, compassionate care to all our patients. Soderma looks forward to helping you define, renew and cherish your health and beauty. For added ease we have made available via www.sodermaskin.com (also by mail by request) our new patient registration forms. This can sometimes be a lengthy process when seeing a new health care provider and we recognize that pertinent information is not always at your fingertips when away from home. So please take some time to review, complete and return the following forms to prior to your appointment via fax or mail. You may also bring your forms into the office directly. Fax To: Mail To: (Proper time allotted for timely receipt) (301) 776-0456 c/o New Patient Registration 13920 Baltimore Avenue Laurel, MD 20707 To better assist you and provide you with an accurate and timely registration process, please review the New Patient Registration Forms checklist below. If you have any questions regarding completing or submitting the following forms please contact us at (301) 776-1094. We all look forward to meeting you and servicing your skin care needs. SODERMA DERMATOLOGY PHYSICIANS & STAFF PATIENT REGISTRATION FORMS CHECKLIST REGISTRATION FORM (1 PAGE) MEDICAL HISTORY FORM (2 PAGES) FINANCIAL RESPONSIBITY FORM (1 PAGE) HIPAA (NOPP) FORM (2 PAGES) PRIMARY CARE PHYSICIAN REFERRAL *(Attach if applicable)
REGISTRATION FORM DATE NAME DOB F /M MARRITAL STATUS: Married Divorced Single Widowed Other Race: Preferred Language: DRIVER S LIC. # STATE EMAIL ADDRESS_ CITY/STATE/ZIP Billing Addresses (If different from above address) HOME # ( ) MOBILE# ( ) WORK # ( ) OCCUPATION EMERGENCY CONTACT NAME/ PH# REFERRING PHYSICIAN NAME/PH# PHARMACY NAME/PH #/FAX# INSURANCE INFORMATION PRIMARY INSURANCE CO ID NUMBER GROUP NUMBER SUBSCRIBER S NAME DOB SUBSCRIBER S EMPLOYER WORK# SUBSCRIBER S SOC.SEC.# RELATIONSHIP HMO PPO REFERRAL: YES / NO SPECIALIST CO PAY $ SECONDARY INSURANCE CO ID NUMBER GROUP NUMBER SUBSCRIBER S NAME DOB SUBSCRIBER S EMPLOYER WORK# SUBSCRIBER S SOC.SEC.# RELATIONSHIP HMO PPO REFERRAL: YES / NO SPECIALIST CO PAY $ I AUTHORIZE AND REQUIRE MY INSURANCE COMPANY TO DISPERSE DIRECTLY TO CYLBURN E. SODEN M.D. P.A. MY INSURANCE BENEFITS. I ALSO AUTHORIZE RELEASE OF MEDICAL INFORMATION THAT MAY BE NECESSARY FOR MEDICAL CARE FOR PROCESSING MY FINANCIAL BENEFITS. I CERTIFY THAT THE INFORMATION I HAVE GIVEN IS CORRECT AND I UNDERSTAND THAT I AM FIANANCIALLY RESPONSIBLE FOR ANY BALANCE NOT COVERED BY MY INSURANCE COMPANY. I AM ADVISED THAT THERE WILL BE A SERVICE CHARGE ASSESSED FOR FAILURE TO CANCEL APPOINTMENTS. FEES ARE AS FOLLOWS: FOLLOW UP APPTS. WITHOUT 24HRS NOTICE $25; SURGICAL APPTS. WITHOUT 48 HRS NOTICE $50 SIGNATURE PRINTED NAME
Today s Date: Patient Name: DOB Briefly describe the reason for your visit today: Select any of the following medical conditions that you currently have: Anxiety Coronary Artery Disease Hypercholesterolemia Arthritis Depression Hyperthyroidism Asthma Diabetes Hypothyroidism Atrial Fibrillation (Irregular Heartbeat) End Stage Renal Disease Leukemia BPH GERD Lung Cancer Bone Marrow Transplant Hearing Loss Lymphoma Breast Cancer Hepatitis Prostate Cancer Colon Cancer Hypertension Radiation Treatment COPD HIV/AIDS Seizures Stroke Other Have you had any surgeries on the following organs? Appendix Joint Replacement: Hip Spleen Bladder Joint Replacement: Shoulder Testicles Breast Kidney Uterus Colon Ovaries Heart: Bypass Prostate Heart: Stent Skin: Biopsy Heart: Valve Replacement Skin: Basal Cell Heart Transplant Skin: Squamous Cell Joint Replacement: Knee Skin: Melanoma Other Do you currently have any of the following? Pacemaker Allergy to topical antibiotics Problems with scarring Defribillator Blood thinners Problems with bleeding Artificial Joints within past 2 years Allergy to lidocaine Problems with healing Premediciation prior to procedures Rapid heartbeat with epinephrine Immunosuppression Allergy to adhesive Pregnancy or planning pregnancy
Have you had any of the following skin conditions? Acne Eczema Precancerous Moles Actinic Keratoses Flaking or Itchy Scalp Psoriasis Basal Cell Carcinoma Hay Fever/Allergies Squamous Cell Carcinoma Blistering Sunburns Melanoma Dry Skin Poison Ivy Other Do you wear sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes No Do you have any family history of melanoma? Yes No If yes, which relatives? Mother Daughter Grandmother Father Son Grandfather Sister Uncle Grandson Brother Aunt Granddaughter Nephew Niece Other Please list all current medications you are taking: Please list any medication allergies: Do you consume or use any of the following? How Often? Tobacco /day, week Drug Use /day, week Alcohol /day, week IV Drug Use /day, week Signature Printed Name
FINANCIAL RESPONSIBILITY I am aware of my financial responsibility towards any co pay or deductibles on my insurance policy. My insurance company, / ID# may not cover certain services. I understand that any unpaid charges are my responsibility. I will pay all applicable co pays, deductibles and outstanding patient balances as they become due. This also applies to secondary insurance policies which may not cover my visit(s). Printed Name Signature Date
NOTICE OF PRIVACY PRACTICES (NOPP) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entitles that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations. Treatment means providing, coordinating or managing health care and related services by one or more health care providers. An example of this would include a physical examination of the skin. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected information. This notice is effective as of April 14 th, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our offices. We will not retaliate against you for filing a complaint. Please contact us for more information: Cylburn E. Soden, M.D., P.A. Dermatologist Laurel Lakes Corporate Center 13920 Baltimore Avenue Laurel, Maryland 20707 (301) 776-1094 For more information about HIPAA, or to file a complaint: The U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, District of Columbia 20201 (202) 619-0257 Toll Free: 1 (800) 696-6775 Signature Date