Download altman dermatology associates

Today’s Date: ________________________
PATIENT INFORMATION
Patient Name: _____________________________________________
(LAST)
Sex:
Male
(FIRST)
Date of Birth: ________________________
(M.I.)
Female
SSN #: _______ - _______ - ___________
Address/ Apt #: __________________________________________________________________________
City: _______________________________________
State: _____
Home Phone #: (
Cell Phone #: (
) _____________________
Email: ____________________________________
Marital Status:
Race:
Single
American Indian
Ethnicity:
Hispanic
Married
Asian
Preferred Method of Contact:
Divorced
Separated
Black or African American
Non-Hispanic
Unknown
Zip Code: ______________
) _________________
Home Phone
Cell Phone
Email
Widowed
Native Hawaiian
White
Other_______________
Preferred Language: ___________________
Employer Name: _________________________________
Occupation: _______________________
Name of Responsible Party (if patient is under age of 18): _____________________________________________________
(LAST)
Relationship to Patient: ______________________
(FIRST)
Responsible Party Phone: (
(M.I.)
) __________________
Responsible Party Address/Apt # (if different than above): _____________________________________________________
City: _______________________ State: ____ Zip Code: _______ Responsible Party Date of Birth: __________________
PRIMARY INSURANCE INFORMATION (In order for us to file a claim on your behalf, this section must be completed in its entirety by the patient.)
Primary Insurance Name: _______________________________________________________________________________
ID#: ____________________________________________
Group/Policy #: ____________________________
Subscriber Name: ____________________________________
Subscriber’s Date of Birth: ____________________
Relationship to Patient: _____________________________
Subscriber’s SSN #: ________ -_______-_______
HMO Primary Care Doctor (if applicable): ___________________________________________________________________
SECONDARY INSURANCE INFORMATION (In order for us to file a claim on your behalf, this section must be completed in its entirety by the patient, if applicable.)
Primary Insurance Name: ________________________________________________________________________________
ID#: ____________________________________________
Group/Policy #: ____________________________
Subscriber Name: ____________________________________
Subscriber’s Date of Birth: ____________________
Relationship to Patient: _____________________________
Subscriber’s SSN #: ________ -_______-________
HMO Primary Care Doctor (if applicable): ____________________________________________________________________
ALTMAN DERMATOLOGY ASSOCIATES
Acknowledgement of Receipt of Information Practices Notice
I understand that as part of my healthcare, this facility originates and maintains health records describing my health history,
symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I
have been provided with and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses
and disclosures of my health information. I understand that the above listed information may be used to:
 Conduct, plan, and direct my treatment and follow up care among multiple healthcare providers, as applicable
 Obtain payment from 3rd party payers
 Conduct normal healthcare operations such as quality assessment and physician certifications
I understand that I may request in writing to have the use or disclosure of my private information restricted in regards to treatment,
payment, and healthcare operations. I also understand that Altman Dermatology is not required to agree to my requested
restrictions. In the case that Altman Dermatology does agree to any restrictions requested, we are bound to abide by them as
stated by you.
Contact Permission
In the event that Altman Dermatology Associates needs to contact you (patient) regarding an appointment, lab results, medication,
or any other reason, it is permitted to:
Check all that apply:
Speak only with patient
Leave a message on an answering machine
Speak with spouse/ significant other
Speak with other family members
Cancellation/ No Show Policy
If the patient cannot attend a scheduled appointment, it is the patient’s responsibility or responsible party to call the office to
cancel 24 hours prior to scheduled appointment.
PLEASE NOTE: Altman Dermatology Associates reserves the right to charge $25 fee if the patient does not cancel their
appointment within 24 hours. Patients scheduled for surgery or cosmetic procedures will be assessed a $50 cancellation fee for
no shows.
Authorization/ Assignment/ Financial Responsibility
By signing below, I certify that I, or my dependent, have benefits issued by the above listed insurance plan(s) as completed by me,
and hereby assign directly to ALTMAN DERMATOLOGY ASSOCIATES any benefit for services rendered. I authorize the release
of information when necessary to secure the payment of such benefits to ALTMAN DERMATOLOGY ASSOCIATES. I authorize
the use of the signature below on all insurance submissions as required. I fully understand that I am responsible for any and all
charges and/or fees associated with services rendered and/or efforts by ALTMAN DERMATOLOGY ASSOCIATES to collect on
monies owed by me. If any account balance should remain unpaid and the account is referred to a collection agency, I agree to
pay any applicable collection fee and I understand that such fees may be added to the account balance.
My signature below indicates that I have read and understood the above statements and agreed upon them.
Patient Name: ___________________________________________________________________________________
Patient Signature (or Responsible Party): ______________________________________
Date: _____ /_____ /_____
Relationship to patient: ____________________________________________________________________________
(Office use only)
I attempted to obtain the patient’s signature but was unable to do so as documented below.
Date:_______________ Initials: ______________ Reason: _____________________________
ALTMAN DERMATOLOGY ASSOCIATES
General Health History
Patient Name: ____________________________________________
Date: ___________________
Preferred Pharmacy Name: ________________________________ Pharmacy Phone #:(
) _____________________
Pharmacy Address: _____________________________________________________________________________________
Social History:
Tobacco Use:
Current everyday (if so,
Alcohol Use:
Current everyday
Heavy
Socially
Light)
Former
Former
Never
Never
Family Medical History:
Do you have a family history of Melanoma?
Yes
No
If yes, which relative (s)? _________________________________________________________________________________
Any other family history: _________________________________________________________________________________
Do you wear Sunscreen?
If yes, what SPF? ___________
Yes
Do you tan in a tanning salon?
Yes
No
No
Female patients:
Are you currently pregnant?
Are you breastfeeding?
Yes
Yes
Are you using contraceptives?
No
No
Yes
No
If yes, please specify: ____________________________________________________________________________________
Are you trying to conceive?
Yes
No
Medications: (Please list all current medications and over-the-counter drugs. Please specify what conditions they are
used for.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Allergies:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
History and Intake Form
Name:_________________________________
Date of Birth:__________________
Past Medical History: (please circle all that apply)
Anxiety
Arthritis
Artificial joints
Asthma
Atrial fibrillation
BPH (Benign Prostatic Hyperplasia)
Bone Marrow Transplantation
Breast Cancer
Colon Cancer
COPD (Emphysema)
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD (Acid reflux)
Hearing Loss
Hepatitis
Hypertension/High Blood Pressure
HIV/AIDS
Hypercholesterolemia/High Cholesterol
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Pacemaker
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Valve Replacement
None
Other: _________________________________________________________________________________________
Past Surgical History: (please circle all that apply)
Kidney Biopsy
Appendix Removed
Kidney Removed (Right, Left)
Bladder Removed
Kidney Stone Removal
Mastectomy (Right, Left, Bilateral)
Kidney Transplant
Lumpectomy (Right, Left, Bilateral)
Ovaries Removed: Endometriosis
Breast Biopsy (Right, Left, Bilateral)
Ovaries Removed: Cyst
Breast Reduction
Ovaries Removed: Ovarian Cancer
Breast Implants
Prostate Removed: Prostate Cancer
Colectomy: Colon Cancer Resection
Prostate Biopsy
Colectomy: Diverticulitis
TURP
Colectomy: IBD
Skin Biopsy
Gallbladder Removed
Basal Cell Cancer Surgery
Coronary Artery Bypass
Squamous Cell Carcinoma Surgery
PTCA
Melanoma Surgery
Mechanical Valve Replacement
Spleen Removed
Biological Valve Replacement
Testicles Removed (Right, Left, Bilateral)
Heart Transplant
Hysterectomy: Fibroids
Joint Replacement, Knee (Right, Left, Bilateral)
Hysterectomy: Uterine Cancer
Joint Replacement, Hip (Right, Left, Bilateral)
None
Joint Replacement within last 2 years
Other _________________________________________________________________________________________
Skin Disease History: (please circle all that apply)
Acne
Actinic Keratoses
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever/Allergies
Melanoma
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin Cancer
None
Other ________________________________________________________________________________________
TO BE COMPLETED BY OFFICE STAFF ONLY:
REVIEWED BY: _______________________________
DATE: ___________________________Revised 04/11/2014