Download Insurance Information - Complete Dermatology

NEW/UPDATED PATIENT INFORMATION
Today's Date:____/____/________ Name: _______________________________________________________________
Address: ___________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________
Home Phone: ________________________ Work Phone: ________________________ Mobile: ____________________
Email Address: ______________________________________________________________________________________
☐ Yes, I'd like to receive quarterly newsletters & promotional offers. I understand I can unsubscribe at any time.
Date of Birth:____/____/________ Age: ______ Sex: ☐ M ☐ F Marital Status: ___________________
Referring Physician's Name: ______________________________________________ Phone: ______________________
Referring Physician's Address: _________________________________________________________________________
Other members of your family who visit this practice: ______________________________________________________
Insurance Information
Primary Insurance
Secondary Insurance
Primary Insurance: ____________________________
Secondary Insurance: _________________________
Insured’s Name: ______________________________
Insured’s Name: ______________________________
Social Security Number: ________-______-_________
Social Security Number: ________-______-_________
Policy #: _____________________________________
Policy #: _____________________________________
Group #: ____________________________________
Group #: ____________________________________
☐ Self
☐ Self
☐ Spouse
☐ Child
☐ Other
☐ Spouse
☐ Child
☐ Other
Insured’s Employer: ___________________________
Insured’s Employer: ___________________________
Insured’s Date of Birth: ______/______/_________
Insured’s Date of Birth: ______/______/_________
Patient's Employer: __________________________________________________________________________________
Occupation: _____________________________________________________________ Full-Time Student? ☐ Yes ☐ No
Emergency Contact: _________________________________________ Phone Number: __________________________
Relationship of Emergency Contact: _____________________________________________________________________
Name of Parent or Guardian (if patient is a minor): _________________________________________________________
How did you hear about us? ☐ Physician Referral (Name) ___________________________________________________
☐ Family Member or Friend Referral ☐ Google/Internet Search/On-line Directory
☐ Employer/Insurance Company ☐ Other _______________________________________________________________
HIPAA AND PRIVACY PRACTICE CONSENT FORM
I acknowledge that Complete Dermatology has made the Notice of Privacy Practices
available to me. I authorize release of medical information to my primary care or referring physician,
to consultants if needed, and as necessary to process insurance claims, insurance applications and
prescriptions. I also authorize payment of medical benefits to the physicians.
_____________________________________
Signature of Patient or Authorized Representative
________________________
Date
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and
disclosures of their Protected Health Information (PHI). The individual is also provided the right to
request confidential communications or that communication or PHI be made by alternative means,
such as sending correspondence to home or office, leaving messages on answering machines, and
leaving lab or procedure results with a spouse.
I wish to be contacted in the following manner:
Phone number:_________________________
o Leave a message with a callback number only
o Leave medical information with my spouse
o Do not leave a message
o Leave a message with detailed information
o Discuss medical information
with:__________________________________
OR
o
o
Text message (when available)
Email (when available)
In the future, I would like to have my appointments confirmed via:
o Cell Phone
o Text Message (when available)
o Email
**Unless a fax machine is in a secure area, Protected Health Information (PHI) cannot be faxed.
This consent will remain in effect unless otherwise revoked in writing.
_______________________________________
Signature of Patient or Authorized Representative
_________________
Date
FINANCIAL POLICY
ACCEPTANCE OF LIABILITY WAIVER
Thank you for choosing Complete Dermatology as your health care provider. It is our goal to meet patient needs and
address patient concerns effectively. Areas of primary concern for all patients are the financial policies of the practice,
especially those pertaining to insurance billing and patient payment requirements. As in all aspects of healthcare today,
the greater role the patient assumes in the healthcare process, the higher the degree of satisfaction achieved. For that
reason, we expect our patients to take an active role in their healthcare management, including the area of finances. In
an effort to keep patients informed about such policies, we ask that all patients read and sign a copy of our Financial
Policy prior to receiving treatment.
PAYMENTS are expected at the time services are rendered. This includes all deductibles, co-insurance, co-payments and
any non-covered services, such as cosmetic procedures. It should be noted that any procedure performed in the office,
such as freezing a wart or performing a biopsy on a mole is considered “office surgery” by all of the major insurance
carriers and may be subject to a deductible. Patients who have an insurance carrier with whom the practice has a valid
contract will be responsible for all fees as outlined in the patients’ contract agreement. We will do everything possible to
verify your insurance benefits including copay amounts and remaining deductibles prior to your visit and provide prompt
refunds for any overpayment. If you believe the information we verified is incorrect, please let one our billing staff know.
INSURANCE is filed for all primary and secondary carriers for whom the practice has a valid contract. The patient is
responsible for filing claims for carriers for whom the practice does not have a valid contract. This includes all carriers
who are secondary to Medicare that are not Medigap crossover carriers. There can be significant variances on services
covered, deductibles, co-pay requirements, network requirements, pre-authorization for services, and other
requirements of the policy. While we will use our best efforts to verify your benefits, ultimately it is the insured’s
responsibility to verify that the services requested and the physicians are covered by the terms of your insurance plan. If
there are any questions the insured is to call his/ her insurance carrier to confirm coverage. If any services are denied as
out of network, not covered by the terms of the policy, policy not in force, not medically necessary, or have a
deductible/co-pay issue, the patient or responsible party will be billed.
PATHOLOGY is ordered by our physicians to properly diagnose certain skin disorders. Accurate pathologic diagnosis is a
skill and the physician interpreting the specimen is a vital part of your healthcare team. For that reason, we utilize a
licensed lab in Dallas led by a very well respected board-certified Dermatopathologist who specializes in the microscopic
diagnosis of skin disorders and was a recent president of the American Academy of Dermatology. Charges for these
services are in addition to your regular physician charges. For your convenience, and to avoid out-of-nertwork charges,
for many insurance plans we may pay the dermatopathology lab directly and file directly with your insurance company.
Pathology charges, then, may come directly from the lab or from our office. We will make reasonable attempts to keep
charges in network. Please note that if any of these services are denied as out of network, not covered by the terms of
your insurance policy, not medically necessary, as requiring a deductible or co-payment, or other related issues, the
patient or responsible party will be billed.
RETURNED CHECKS will result in a $25.00 service charge. The check amount plus the service charge is to be paid within
10 days of notification. Failure to pay in full in 10 days will result in collection through the appropriate means.
WALK OUT POLICY: Payment for services is expected at the conclusion of your appointment. Any patient that walks out
of our offices without making or arranging payment will be assessed a $40.00 walk-out fee.
“NO SHOW”/ LATE CANCELLATION POLICY: If you are unable to attend an appointment, please let us know as soon as
possible so that we can assign your time slot to someone else. We ask for at least one business day cancellation notice
for all appointments. We reserve the right to charge the following “late cancellation fees” or “no show fees”:
 $25.00 for an office visit;
 $50.00 for a procedure visit (surgery or cosmetic procedure)
As a courtesy, we make every effort to call to confirm appointments in advance; however, it remains YOUR responsibility
to know and to keep your appointment. Emergencies are considered on an individual basis. Contact our office as soon as
possible to discuss any emergency situation which caused you to miss an appointment.
LATE POLICY: If you are more than 15 minutes late to your scheduled appointment, we will make every effort to work
you back into the provider's schedule. However, we may have no choice but to reschedule your appointment.
REQUESTS FOR MEDICAL RECORDS and COMPLETION OF FORMS (such as Cancer Policy, Disability, …) will be charged at
$25.00 per request. Upon receipt of payment, documentation will be returned or can be picked up within 3-5 business
days, unless otherwise notified.
STATEMENTS & BILLING CORRESPONDENCE are sent to update you as to the status of the account and whether your
insurance company has fulfilled their obligation to you, the policy owner, to pay claims in a timely manner.
DELINQUENT ACCOUNTS are placed for collection 90 days from the date the services were rendered or from the date of
the first billing statement, whichever applies. These accounts will be charged a cumulative interest rate of 10% and/or
$25.00 collection fee on all outstanding charges. Patients having financial difficulties are encouraged to discuss them
frankly with our Practice Manager before the account becomes delinquent.
CREDIT CARDS, CHECKS, CARE CREDIT, and CASH are accepted for payment.
I have read the Financial Policy of Complete Dermatology. I understand and agree to adhere to the policies as outlined. I
further agree to be responsible for all charges not covered by the terms of my insurance plan.
_____________________________________________________________________________
Patient Name(s)
_____________________________________________________ _______________________
Signature of Responsible Party
Date
Medical History Questionnaire
Name:_____________________________________________________________ Date of Birth: _____/_____/________
The reason for your visit: _____________________________________________________________________________
How long has this been present? _________________What have you tried to treat it? ____________________________
Drug Allergies: ______________________________________________________________________________________
PERSONAL DERMATOLOGIC HISTORY
*Please check if you have a history of:
☐ Skin Cancer
Which Type?
☐ Melanoma - When? ______________ Location? ___________________
☐ Basal Cell Cancer - When? ______________ Location? ___________________
☐ Squamous Cell Cancer - When? ______________ Location? ___________________
☐ Actinic Keratosis (Precancerous Skin Growth)
☐ Eczema
☐ Psoriasis
☐ Lupus
☐ Scarring Acne
☐ Other dermatologic condition(s) ____________________________________________________________
MEDICAL HISTORY
*Please check if you have a history of:
☐ Allergies/Sinusitis
☐ Artificial Heart Valve
☐ Asthma
☐ Bleeding Disorder
☐ Cancer (other than skin cancer)
Which type? ______________
☐ Cataracts
☐ Cold Sores (Herpetic Infection)
☐ Congestive Heart Failure
☐ Depression
☐ Diabetes
☐ Diabetes Mellitus
☐ Emphysema/COPD
☐ Epilepsy
☐ GERD/(Reflux Disease)
☐ Glaucoma
☐ Heart Arrhythmia
☐ Heart Disease
☐ Hepatitis
☐ High Cholesterol
☐ HIV or AIDS
☐ Hypertension
☐ Irritable Bowel Syndrome
☐ Mitral Valve Prolapse
☐ Organ Transplant
☐ Osteoarthritis
☐ Osteoporosis
☐ Rheumatic Fever
☐ Rheumatoid Arthritis
☐ Stomach Ulcer
☐ Thyroid Disease
☐ Tuberculosis
☐ Other _______________________
SOCIAL HISTORY Do you wear sunscreen regularly? Yes No
Do you smoke? Yes No
FAMILY HISTORY
Use tanning beds? Yes No
Drink alcohol? Yes No Use drugs? Yes No
*Do any family members suffer from the following?
Condition:
Family Member (Relationship)
Skin Cancer (other than melanoma)
Melanoma
Asthma/Eczema/Seasonal Allergies
Psoriasis
For Women: Are you currently pregnant OR actively trying to get pregnant OR breastfeeding?
Are you interested in cosmetic products or procedures?
Have you had any cosmetic procedures in the past?
Yes
Yes
No
No
Yes
No
Anything specific? ________________________________
Were you happy with the results Yes
No