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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Tel : 561-594-0050 Fax: 888-677-3527 [email protected] www.junodermatology.com 3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410 PLEASE COMPLETE THE ENTIRE FORM. IF NOT APPLICABLE, AFFIX N/A. First name:________________________________ Address: _________________________________ Email: _________________________________ Preferred language:*________________________ SSN: ___________________________ Date of birth: ___________________________ Primary phone # _________________ Type: _____ Secondary phone #________________Type: _____ *Recent government reforms require this information. This applies to all patients. Last name: _________________________________________ City________________State:_________ Zip code_______ Employment status: [ ] Employed [ ] Retired [ ] Other _______________ Employer: ___________________ Office # ________________ Student status: [ ] Full [ ] Part School name: ________________ Emergency contact: _______________Phone#:__________ Emergency contact relationship :________________________ Primary provider: __________________________________ Referring physician: __________________________________ Referral source: [ ] Insurance Directory [ ] Google Preferred contact method: [ ] Text [ ] Phone Gender: [ ] Male [ ] Female Race:* [ ] White [ ] Black/ African American INSURANCE INFORMATION [ ] Hispanic [ ] Native Hawaiian [ ] Asian [ ] Other [ ] American Indian Primary insurance: __________________________ Name Policy holder:_________________________ Date of Birth: ________ Relationship:_______ Member #: __________________________ Group #: __________________________ Group name: __________________________ Effective: __________________________ [ ] Provider [ ] Event [ ] Other: ___________________________ Marital Status: [ ] Married [ ] Single: ___________________ Ethnicity:* [ ] Hispanic/ Latino [ ] Not Hispanic/ Latino [ ] DECLINE Secondary insurance: ____________________________ Name Policy holder: ____________________________ Date of Birth: ________ Relationship:_________ Member #: ____________________________ Group #: ____________________________ Group name: ____________________________ Effective: ____________________________ PLEASE INDICATE INITIAL: The information I provided above is truthful and accurate, and any discrepancy may result in further clarification. (Required) I authorize Juno Dermatology, LLC to furnish information concerning my condition and treatment to my insurance carrier(s). If you do not want us to submit your visit info to your insurance, the patient/financially responsible party accepts the full financial responsibility for cost incurred during the visit(s). (Required) I authorize payment of medical benefits to Juno Dermatology, LLC. (Required) I understand that I am responsible for any part of the charges that are not covered by my insurance. (Required) I understand that I will be charged $50 fee for cancellations made less than 24 hours before scheduled appointment. (Required) I give my permission to Juno Dermatology, LLC to email me promotional offers on products and services. (Optional) ________________________________________________ ___________________________________________ SIGNATURE (Patient or Parent/Guardian if patient is a minor) TODAY’S DATE Tel : 561-594-0050 Fax: 888-677-3527 [email protected] www.junodermatology.com 3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410 Please read carefully and initial each paragraph. PHOTOGRAPHY The undersigned patient or legal guardian hereby authorizes Juno Dermatology, LLC to take, use, and copy a photo of patient, including but not limited to the face. The photo(s) will only be used for purposes of identification and documentation of the progress of patient's condition. I understand that no photographic image of the patient will be disseminated outside of Juno Dermatology, LLC for commercial purposes without my further consent. USE OF PROTECTED HEALTH INFORMATION I authorize Juno Dermatology, LLC to use and disclose Protected Health Information (PHI) of the patient for the purposes of carrying out treatment, payment, and healthcare operations (TPO). The complete description of such uses and disclosures can be found in our Notice of Privacy Practices. I received a copy of the Notice of Privacy Practices prior to signing this consent. With this consent, Juno Dermatology, LLC may call and/or send mail to me or to person listed on the Patient Disclosure form in order to assist them in carrying out TPO. This includes but is not limited to appointment reminders, insurance items, laboratory results, financial statements and any other information pertaining to my clinical care. I understand that I may revoke my consent in writing, except for the information that the practice has already made disclosures of before the consent was revoked. Juno Dermatology, LLC reserves the right to decline treatment to me/the patient once the consent has been revoked. _________________________________ Patient's Name _________________________________ Date _________________________________ Patient/ Legal Guardian Signature _________________________________ Printed Name of Guardian Tel : 561-594-0050 Fax: 888-677-3527 [email protected] www.junodermatology.com 3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410 Commercial and non-commercial insurance Juno Dermatology, LLC will bill your insurance(s) for services rendered during your visits provided that your insurance carrier will make payments directly to Juno Dermatology, LLC. Medicare Juno Dermatology, LLC will accept assignment from Medicare. The patient is responsible for the 20% co-payment. If you have a Medicare supplement, we will file a claim with them provided they will make payments directly to Juno Dermatology, LLC. Referrals If your insurance requires a referral from your primary care physician (PCP), please make sure that your PCP has been notified of this appointment. A copy of the referral must be provided to you and Juno Dermatology, LLC prior to your appointment. Juno Dermatology, LLC is not responsible for procuring referrals. Claim Submission In the event the patient has insurance coverage but cannot provide documentation, charges will be entered as self-pay. Upon the submission of the insurance card, we will submit a health insurance claim form. Secondary insurance will be billed upon the submission of proof of secondary insurance. Juno Dermatology has the right to deny use of insurance card if patient's name on the card does not match that listed on a government issued identification card. Insurance Release I authorize Juno Dermatology, LLC to release required information to my insurance company, hospitals and other medical providers regarding services provided, including medical, laboratory studies, HIV testing, and other medical data related to my care. Financial agreement I understand that my insurance contract is between me and my insurance company. In the event the insurance does not pay for billed services, the balance will be the patient's/ legal guardian's responsibility. Juno Dermatology, LLC will forward the account to collections if the patient fails to settle the account balance on the due date or fails to make suitable financial arrangements. The patient/legal guardian will be responsible for collection fees that may include but not limited to court fees, attorney fees, and any other fees incurred during the collection process. Moreover, I consent to Juno Dermatology, LLC making appropriate inquiry on my credit history in conformity with legitimate business needs and applicable laws, rules, and regulations. Forms and Release of Records The completion of administrative forms about your care and duplication of records is not a part of your routine medical services with us. We are happy to assist you in any way possible, but we reserve the right to charge appropriate fees for these extra services, based upon time and effort involved. If you request copies, we charge you up to $15.00 to locate and copy your records, plus postage if you want them mailed to you. Requests must be made in writing by completing our record release form. There is no cost to provide records to facilities or physicians that we refer you to see. _____________________________ ____________________________ Patient's Name Date ________________________________ Patient / Legal Guardian Signature _______________________________ Printed name of Guardian Tel : 561-594-0050 Fax: 888-677-3527 [email protected] www.junodermatology.com 3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410 Patient's name: _______________________________________________________________________ Date of birth: ________________________________________________________________________ Past Medical History: Asthma Emphysema Seasonal/Food Allergies High Cholesterol High Blood Pressure Heart Disease Heart Murmur Artificial Heart Valve Pacemaker/ Defibrillator Bleeding Disorder Blood Clots Thyroid Disease Diabetes Kidney Disease Gastro-Esophageal Reflux Duodenal or Peptic Ulcer Inflammatory Bowel Disease Gluten Sensitivity/Celiac Disease Hepatitis Autoimmune Disorder Neurologic Disorder Arthritis Artificial Joints Cancer (please specify) _____________ Radiation Therapy Organ Transplant Tuberculosis STDs (HPV, herpes, syphilis, gonorrhea, chlamydia, other)___________________________ Immunodeficiency/HIV Emotional Disorder NONE OTHER: ____________________________________ ______________________________ Past Surgical History (please list any surgeries with dates, if available): ___________________________________________________________________________________________ _____________________________________________________________________________ Skin Disease History : Acne Rosacea Blistering Sunburns Actinic Keratoses Basal Cell Skin Cancer Squamous Cell Skin Cancer Precancerous Moles (AKA, Dysplastic) Melanoma Dry Skin Eczema Flaking or Itchy Scalp Psoriasis None OTHER: ____________________________________ ____________________________________ ____________________________________ ________________________ Tel: 561-594-0050 Fax: 888-677-3527 [email protected] www.junodermatology.com 3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410 Do you wear Sunscreen? Yes No If yes, what SPF? _____ Do you tan in a tanning salon (past or present)? Yes No Do you have a family history of melanoma? Yes No If yes, which relative(s)? _________________________________________________________________________ _________________________________________________________________________ Any other family history of skin disease: _________________________________________________________________________ Medications (please enter all current medications, dose and frequency, if known): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Allergies (please list all allergies): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Social History: Cigarette Smoking: Never smoked Quit: former smoker Smoke less than daily Smoke daily Alcohol Use: YES ______________glass/day NO Pharmacy: Name: ____________________________________________________________________ Phone number: ____________________________________________________________________ Zip code: ____________________________________________________________________ Family History: CANCER: _____________________________ DIABETES:_____________________________ HEART DISEASE: ________________________ HYPERTENSION:________________________ OTHER:_______________________________ Mother | Father | Brother | Sister| Mother | Father | Brother | Sister| Mother | Father | Brother | Sister| Mother | Father | Brother | Sister| Mother | Father | Brother | Sister| Tel: 561-594-0050 Fax: 888-677-3527 [email protected] www.junodermatology.com 3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410 Review of Systems: Problems with bleeding Problems with healing Problems with scarring (Hypertrophic/keloid) skin Immunosuppression Hay Fever Chest pain Fever or chills Night sweats Unintentional weight loss Blurry vision Abdominal pain Bloody stool Bloody urine Joint aches Muscle weakness Neck Stiffness Headaches YES YES YES NO NO NO YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO Seizures Cough Shortness of breath Wheezing Allergy: Adhesive Allergy: Lidocaine Allergy: Topical Antibiotic Artificial: Heart Valve Artificial: Joints within 2 yrs Blood thinners Rapid Heart Beat with epinephrine Pregnancy or planning Preg. Breastfeeding Defibrillator MRSA Pacemaker Would you be interested to learn more about cosmetic procedures that we offer? If yes, please choose from the following: Botox®Cosmetic Laser hair removal Laser for freckles, sun damage Professional Grade Skin care Fillers (Juvederm®, etc) Laser for facial blood vessels Laser Scar treatment Customized Facials YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES YES YES YES YES Yes No Laser skin resurfacing Microdermabrasion Chemical Peels NO NO NO NO NO Tel : 561-594-0050 Fax: 888-677-3527 [email protected] www.junodermatology.com 3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410 I hereby give authorization to speak to the following people regarding my illness/condition. ____________________________ Name ____________________________ Name ____________________________ Name ____________________________ Name ___________________ _____________________ Relationship Phone number ___________________ _____________________ Relationship Phone number ___________________ _____________________ Relationship Phone number ___________________ _____________________ Relationship Phone number I understand that this authorization will expire in 1 year unless otherwise specified. _________________________________ Patient's signature _________________________________ Patient's name ______________________________ Date ______________________________ Date of Birth