Registration Form

Driver's License

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Insurance Card (Front)

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Insurance Card (Back)

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WELCOME

We are committed to providing you with quality medical care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or responsibility.

To assist us in establishing your account please (1) provide current insurance information on the patient registration form and (2) authorize the release of information necessary for insurance filing and pre-certification. Failure to do so will affect your financial responsibility for charges incurred. Your payment can be in the form of cash, check, or credit card.

REGARDING INSURANCE

Contracted Managed Healthcare Plans ( PPO, POS, EPO): Each time you make an appointment, it is your responsibility to make sure that this office is currently under contract with your plan(s), and you have obtained the necessary referrals. Verification of your plan is required. Often, this verification requires us to share the reasons for your visit with your managed care plan. Please plan to show your current insurance card(s) and a picture id (e.g. Driver's license) to our staff upon request. Co-payment, co-insurance, deductible, and/or fees for non-covered service are required at the time of service.

Insurance is a contract between your insurance company and you. We are not a party to your contract. We will not become involved in disputes between your insurance company and you regarding deductibles, non-covered/covered charges, coinsurance, secondary insurance, coordination of benefits, pre-existing conditions, or “reasonable and customary” charges, other than to supply factual information as necessary. You are responsible for the timely payment of your account, and /or your dependents' accounts.

Many services performed in our office (biopsies, liquid nitrogen, etc,) are considered surgical procedures by your insurance company. These services may be covered by your insurance company but may be subject to a deductible or co-insurance. Any deductible, co-insurance, or non-covered service, is your responsibility to pay, and we may ask for payment at the time of service. Surgical procedures may include but are not limited to: treatment of warts and molluscum; removal of moles, skin cancers, benign growths and cysts; treatment of pre-skin cancers; acne surgery; keloid treatments; nail plate biopsy/ clipping; and drainage of abscesses.

After 60 days, it is the patient's responsibility to pay the balance on their account even if there's an insurance claim pending. We will no longer be responsible for collecting your insurance claim or for negotiating a settlement of a disputed claim.

Any account past due more than 60 days may be assessed an interest charge per month on the unpaid balance and a $30.00 billing fee. If my account is referred to a collection agency, or credit-reporting agency, or a lawyer, I agree to pay all associated costs incurred. Any amounts due from me cannot be discharged in bankruptcy and are binding on me, my assigns, heirs, executors, or estate.

MISSED APPOINTMENTS

Unless canceled or rescheduled at least 24 hours in advance, our policy is to charge a $50 fee for missed appointments. This fee is not covered by insurance. Please help us serve you better by keeping your scheduled appointment.

This agreement applies and relates back to all occasions of service until Sugar Land Dermatology revokes or replaces it. A copy of this agreement serves as an original.

I have read and understand the above terms and conditions and will verify so by giving my signature.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Responsible Party:

Date:

PATIENT INFORMATION SHEET

If not applicable, type "none" into the field.

Personal

Legal Name:

First Name

Middle Name:

Today's Date:

Address:

Apartment #:

City:

State:

Zip Code:

Home Phone

Cell Phone:

Work Phone:

Date of Birth:

Sex:

Male Female

Referring Doctor:

Employer:

Occupation:

Marital Status:

Single Married Divorced Widowed Separated

Email:

Spouse Name:

Phone:

Emergency Contact:

Phone:

Relationship:

Add Local Pharmacy

Name

City

State

Zip-code

Phone

Fax

INSURANCE

Primary Insurance Name:

Primary Insurance Policy #:

Group #:

Secondary Insurance Name:

Secondary Insurance Policy #:

Group #:

PLEASE COMPLETE IF PATIENT IS NOT THE POLICY HOLDER: PRIMARY OR SECONDARY INS.

Policy Holder Name:

Date of Birth:

Employer:

Work #:

Sex:

Male Female

Office Use Only:

P INS ID

INT:

Portal Enabled:

Yes No

If No, Why

Date:

ASSIGNMENT OF BENEFITS:

(PLEASE READ CAREFULLY AND SIGN)

I hereby authorize the physician and/or staff to release my medical information to my insurance company, spouse, or other family members. Messages from this office may be left on my answering machine at home or cell.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

I further authorize payment to the physician, of benefits due for services rendered. I understand that I am financially responsible for charges that are not covered by my Insurance company.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

MEDICAL HISTORY

Patient:

Date:

Reason for today's visit:

Are you allergic to any medications?

Yes No

If yes, please list:

Add Medication allergy

Are you currently taking any medications, supplements, vitamins, topical creams, and ointments? (Include any over the counter skin products.)

Yes No

If yes, please list:

Add Medication/Supplement

Do you have now, or have you ever had diseases or conditions of:

Lungs:

Bronchitis

Yes No

Emphysema

Yes No

Asthma

Yes No

Chronic Cough

Yes No

Vascular

High Blood Pressure

Yes No

Heart Murmur

Yes No

Pacemaker

Yes No

Chest Pain

Yes No

Irregular Heartbeat

Yes No

Phlebitis

Yes No

Heart Attack

Yes No

Other Systemic:

Diabetes

Yes No

Bladder

Yes No

Glaucoma

Yes No

Arthritis/Joint Deformity

Yes No

Thyroid

Yes No

Stomach

Yes No

Fainting

Yes No

Hepatitis or Yellow Skin

Yes No

Kidney

Yes No

Bowel

Yes No

Other:

If answer is "Yes" to any of the above, please explain:

Do you have, or have you been exposed to HIV (AIDS)?

Yes No

Have you ever had dental anesthesia (Novacaine)?

Yes No

Did you have a bad reaction?

Yes No

Do you have any children?

Yes No

If yes, please specify Age and Sex:

Add Child

Do you have any siblings?

Yes No

If yes, please specify Age and Sex

Add Sibling

Skin

When you are exposed to sun do you:

Tan only Tan and burn Burn

Have you ever had skin cancer or melanoma?

Yes No

If yes, what type and where?

Has anyone in your family had skin cancer or melanoma?

Yes No

If yes, who?

Do you have a history of any specific skin diseases?

Yes No

If yes, please list:

Add Skin Disease

Have you had any surgical procedures in the last six months?

Yes No

If yes, please list:

Add Another Surgery

Please answer the following questions:

A: Do you smoke?

Yes No

If yes, how much and how long?

B: Do you drink alcohol?

Yes No

If yes, how much in one week?

C: Do you bleed easily?

Yes No

D: (Women) Are you pregnant?

Yes No

If yes, due date:

E: Do you have artificial joints?

Yes No

F: What is your occupation?

G: What are your hobbies?

Completed by:

Patient Family Member

If family member please specify:

First Name

Last Name

Relationship to Patient

Office use only:

Signed by Physician:

Date

PATIENT CONSENT FORM

Our Notice of Privacy practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

Protected health information may be disclosed or used for treatment, payment, or health care operations
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
The Practice reserves the right to change the Notice of Privacy Polices
The patient has the right to restrict the uses of their information, but the Practice does not have to agree to those restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
The Practice may condition treatment upon the execution of this Consent.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

This Consent was signed by:

Relationship to Patient:

Date:

Office Use Only:

In front of:

Your information will be encrypted.