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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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