New Patient Forms

Catalina Dermatology

PATIENT INFORMATION

First Name

M.I.

Last Name

Date of Birth

Gender

M F

SS#

Home Phone

Work Phone

Cell Phone

E-mail Address

Marital Status

S M W Sep

Address

City

State

Zip Code

Employer

Occupation/Previous Occupation

Referring Physician

Race/Ethnicity

Primary Care Physician

RESPONSIBLE PARTY INFORMATION

First Name

M.I.

Last Name

Date of birth

SS#

Home Phone

Work Phone

Employer

Occupation

Relationship to Patient

EMERGENCY CONTACT

First Name

M.I.

Last Name

Address

Telephone

INSURANCE INFORMATION

Primary Insurance Company

ID #

Policy #

Group #

Policyholder's Name

Relationship to Patient

Date of Birth

Policy Holder's Employer

Secondary Insurance Company

ID #

Policy #

Group #

Policyholder's Name

Relationship to Patient

Date of Birth

Policy Holder's Employer

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

I authorize payment of medical benefits to the provider for services rendered or to be rendered in the future, without obtaining my signature on each claim submitted, and the signature will bind me as though I personally signed the claim. I also authorize the release of any medical information necessary . I UNDERSTAND AND I AM RESPONSIBLE FOR ALL CHARGES. If this account should be referred to a collection agency, I will be responsible for any collection and/or legal fees. I have read and understand the office policy and procedure.

Responsible Party Signature

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of CATALINA DERMATOLOGY'S "Notice of Privacy Practices." This Notice describes how CATALINA DERMATOLOGY may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information and rights I may have regarding my protected health information.

Signature of Patient or Personal Representative

Date

PATIENT FINANCIAL RESPONSIBILITY AGREEMENT

Thank you for choosing Catalina Dermatology as your healthcare provider!

The medical services you seek here imply an obligation on your part to ensure payment in full is made for services you receive. This Patient Financial Responsibility Agreement will assist you in understanding that financial responsibility.

Consent: I consent to treatment and services ordered by my Physician or Physician Assistant at Catalina Dermatology. I understand my healthcare provider may perform medically necessary services, as well as “elective” services, according to current standard of care guidelines. I do have the right to consider or decline services prior to them being performed. My consent to undergo treatment and/or services will be considered a non-verbal agreement to pay for the services provided to me.

Responsibility: I understand that I am ultimately responsible for all payment obligations arising out of my treatment and care and I guarantee payment for these services. I am responsible for deductibles, co-payments, co-insurance, or any other patient responsibility amounts indicated by my insurance carrier, pursuant to my particular plan. I am also responsible for any services not covered by my insurance.

Insurance Policy: It is my responsibility to know and understand my insurance policy, both the coverage benefits and the policy limitations. I understand that I am personally responsible for payment when: (i) my health plan requires prior authorization/referral by a primary care physician (PCP) before receiving services, and I have not obtained such an authorization or referral; (ii) I receive services in excess of the authorization/referral; (iii) my health plan determines the services I received are not medically necessary and/or not covered by my insurance plan; (iv) my coverage has lapsed/expired at the time services are rendered; (v) I have chosen to utilized my out-of-network benefits; or (vi) I have chosen not to use my health plan coverage for services I receive.

Payment Arrangements: Whether I have insurance or I am self-pay, payment of my account balance is due within ten (10) days of receipt of my billing statement. I understand if I need to make special payment arrangements, I may contact the billing staff to arrange a mutually agreeable payment plan. I agree to make payments on this plan pursuant to the plan agreement until my account is paid in full. If my account is over sixty (60) days past due, my account will be in default and may be referred to a collection agency or attorney.

Payments Accepted: I understand that I can make payments by check, cash, money order, debit card or credit card (Visa, MasterCard, American Express or Discover).

Payment by Check: If my check payment is returned or declined for any reason, my account will be charged a surcharge of $35.00 in addition to any costs assessed or charged by the bank. After two (2) returned checks have been received by Catalina Dermatology, my personal checks will no longer be accepted and I will be responsible for using another method of payment.

Non-Payment on Account: Should collection proceedings or other legal action become necessary to collect my overdue or delinquent account, I understand Catalina Dermatology has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. I am responsible for all costs of collection, including, but not limited to: (i) late fees and charges and interest due as a result of such delinquency; (ii) interest of 18% per year accrued on the principal balance owing; and (iii) all attorney/court costs and fees incurred in the collection process. I acknowledge that if my account is referred to a collection agency or attorney, or when the past due status is reported to a credit reporting agency, it may have an adverse impact on my credit history. Once my account is placed with a collection agency or attorney, I am responsible for communicating with their offices for payment. I may lose my ability to be seen at Catalina Dermatology as a result of my account being sent to a collection agency or attorney.

Minor Patients: The parent/guardian presenting with a minor for care is the responsible party for the payment of the minor’s account balance regardless of any court order or arrangement to which the parents may have agreed. Catalina Dermatology will not act as administrator to resolve financial agreements.

Authorization to Contact: I authorize Catalina Dermatology, or any collection agency or attorney hired by Catalina Dermatology, to communicate with me by mail, answering machine message, text message or email. I may be contacted for purposed related to my account, including debt collection, using any information I have provided, including contact information, email addresses, cell phone numbers, and landline numbers. I authorize Catalina Dermatology to use this information in any manner consistent with the information I have provided, including mail, telephone calls, e-mails, or text messages. I expressly understand that this contact may result in charges to me and may include the use of text message, automated dialing machines or other telephone technology, including the use of live, pre-recorded or artificial voice messages.

Acknowledgement: I understand I am ultimately responsible for payment of services I receive at Catalina Dermatology, regardless of my health insurance coverage. I understand that Catalina Dermatology will not act as administrator to resolve my personal financial agreements in regard to my medical care. I have had the opportunity to read this Patient Financial Responsibility Agreement in its entirety and have had the opportunity to ask questions regarding the details of this Agreement. Any questions have been answered to my satisfaction.

I consent and agree to the aforementioned policies of Catalina Dermatology and understand they may be altered without notice.

Signed and agreed to this date:

Patient Name

Signature

Date of Birth

Parent/Guardian Name

Signature

Date of Birth

CANCELLATION AND NO SHOW POLICY

Should it become necessary for you to cancel or reschedule your appointment, we request 24 hours notice. This allows us to offer appointments to other patients who are scheduled in the future and necessitate being seen sooner, or patients who need to be seen on a urgent basis.

A patient who fails to show for a scheduled appointment or a patient who cancels his/her appointment with less than 24 hours notice will be charged a fee as follows:

Established patients:

$50.00

New Patients

$150.00

Procedure/MOHS

$150.00 - $300.00

Thank you for courtesy and cooperation,

Catalina Dermatology

By signing below, I agree that I have read and understand the above policy.

Signature of Patient

Date

Witness Signature

Date

Patient's Authorization Request Form

You may give Catalina Dermatology and Dr. Mann (the Practice) written authorization to disclose your protected health information (PHI) to anyone you designate and for any purpose. If you wish to authorize a person or entity to receive your PHI, please complete the information below. Completion of this form will not change the way the Practice communicates with you as a patient. For example, the Practice will send statements, appointment reminders, give pathology results, etc. when appropriate.

Patient Name:

Date of Birth:

Patient SSN#

At my request, I authorize this Practice to disclose my Protected Health Information to: (enter name of person/entity who will receive you PHI)

1. Name

Relationship to Patient

2. Name

Relationship to Patient

Please provide the following information to the person you have authorized so that we may verify the person's identity and authority to receive your information: 1. Your SSN 2. Your date of birth.

I authorize this Practice to release the following information to the person/entity listed above.

Check all that apply:

Account Information

All claims Information

Explanation of insurance (EOB) info

Pathology Reports

Laboratory Reports

Any requested information

Other: (Please list specific health information):

I would like this authorization to expire on (enter date)

(If no expiration date is listed, this authorization will expire one year from date of receipt.)

I understand that I may revoke this authorization at any time by giving the Practice written notice. However, if I revoke this authorization, I also understand that the revocation will not affect any action the Practice took in reliance upon this authorization before the Practice received my written notice.

I also understand that the Practice will not condition the way medical treatment will be given because of this authorization.

I also understand that if the persons or entities I authorize to receive my PHI are not health plans, covered health care providers or health care clearinghouses subject to Health Insurance Portability and Accountability Act (HIPPA) or other federal health information privacy laws, they may further disclose the PHI and it may no longer be protected by HIPPA or federal health information privacy laws.

Signature of patient

Date

If signed by personal representative,

Enter your full name:

Describe your authority to act for the patient (e. power of attorney, court order, parent of a minor, etc):

Please attach legal documentation naming you as the personal representative.

Note: Catalina Dermatology and Dr. Mann will consider the effective date of this authorization to be the date the Practice enters this authorization into its system, typically 5 business days following receipt. If you would like this authorization to become effective on a date after the practice enters the authorization into its system, please insert the date here:

Date:

If you chose to decline this authorization, please sign below.

Signature

Date

Patient Medical History

Patient Name:

Date

Patient Phone No:

Ins. Co:

Referring Physician:

Primary Care Physician:

Drug Allergies:

Medications presently taking:

Do you have a personal history of any of the following: (Select Yes or No)

Diabetes

Yes No

Radiation Therapy

Yes No

High Blood Pressure

Yes No

HIV Infection

Yes No

Heart Disease

Yes No

Kidney Disease

Yes No

Heart Disease (Type)

Pacemaker

Yes No

Lung Disease

Yes No

Implanted Defibrillator

Yes No

Arthritis

Yes No

Artificial Heart Valve

Yes No

Hepatitis

Yes No

Joint Replacement

Yes No

Hepatitis (Type)

Bleeding Disorders

Yes No

Cancer (Other than skin)

Yes No

Neurologic Disease

Yes No

Cancer (Type)

Seizures

Yes No

Skin Cancer

Yes No

Auto-Immune Disease

Yes No

Skin Cancer (Type)

Auto-Immune Disease (Type)

Keloidal Scars

Yes No

Tobacco Use

Yes No

Liver Disease

Yes No

Alcohol Use

Yes No

Organ Transplant

Yes No

List any other significant health problems:

Have you had a history of problems with surgery/or anesthesia?

What previous surgeries have you had and when?

FAMILY HISTORY

Do your parents, siblings or grandparents have any of the following?

Skin Cancer

Yes No

Type

Skin Disease (e.g. eczema, psoriasis)

Yes No

Type

Other Cancers

Yes No

Type

Diabetes

Yes No

Arthritis

Yes No

Heart Disease

Yes No

Other

Yes No

Type

SOCIAL HISTORY

Are you married or single?

M S

Do you live alone?

Yes No

Do you exercise routinely?

Yes No

Do you have a drug or alcohol habit?

Yes No

Flu Shot?

Yes No

Date

Pneumonia Vaccine?

Yes No

Date

REVIEW OF SYSTEMS

Do you have any significant problems in any of the following areas? Head, ears, eyes, nose, throat

Eyes

Yes No

Ears

Yes No

Mouth

Yes No

Throat

Yes No

Sinus Problems

Yes No

Head

Yes No

If you answered yes to any of the above, please explain:

Cardiovascular

Chest Pains

Yes No

Pain in Legs

Yes No

Irregular Heart Rate

Yes No

Blood Pressure

Yes No

If you answered yes to any of the above, please explain:

Gastrointestinal

Swallowing

Yes No

Heartburn

Yes No

Nausea

Yes No

Frequent stomach discomfort

Yes No

Diarrhea

Yes No

Rectal Bleeding

Yes No

Bloody or Black Stool

Yes No

Vomiting

Yes No

If you answered yes to any of the above, please explain:

Genital/Urinary

Difficulty Urinating

Yes No

Blood in Urine

Yes No

Menstrual Problems

Yes No

If you answered yes to any of the above, please explain:

Musculoskeletal

Joint Pains

Yes No

Muscle Pain

Yes No

Back Problems

Yes No

Arm in motion problems

Yes No

Hand Movement Problems

Yes No

Problems Walking

Yes No

If you answered yes to any of the above, please explain:

Neurologic

Seizures

Yes No

Frequent Headaches

Yes No

Problems with Speech

Yes No

Stroke

Yes No

If you answered yes to any of the above, please explain:

Respiratory

Breathing Problems

Yes No

Coughing

Yes No

Coughing up Blood

Yes No

Shortness of Breath

Yes No

If you answered yes to any of the above, please explain:

Skin

Rash

Yes No

Changing Moles

Yes No

Frequent Hives

Yes No

Persistent Itching

Yes No

Easily Bleeding Sore

Yes No

If you answered yes to any of the above, please explain:

If you take aspirin or aspirin containing medications or nonsteroidal medications, please inform the physician. We thank you for taking the time to complete this form.

Patient Signature:

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

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW IT CAREFULLY

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US

Protected health information about you is obtained as a record of your contacts or visits for healthcare services with CATALINA DERMATOLOGY. This information is called protected health information. Specifically, “Protected Health Information” is information about you, including demographic information (i.e., name, address, phone number, etc.) that may identify you and relates to your past, present or future physical or mental health condition and related health care services.

CATALINA DERMATOLOGY is required to follow specific rules on maintaining the confidentiality of your protected health information, how our staff uses your information, and how we disclose or share this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your protected health information. It also describes how we follow those rules and use and disclose your protected health information to provide your treatment, obtain payment for services you receive, manage our health care operations, and for other purposes that are permitted or required by law.

If you have any questions about this Notice, please contact or Privacy Manager at (520) 529-8883

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office:

Treatment: We may use or disclose your health information to provide, coordinate, or manage your health care and any related services. We could disclose your protected health information to a physician or other healthcare provider providing treatment to you, to a pharmacy filling your prescriptions, or to family and friends you approve.

We may also call you by name in the waiting room when the physician is ready to see you, and contact you by telephone to remind you of your appointment or inform you of test results.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include also include certain activities that your health insurance plan may undertake before it approves or pays for the services we recommend, such as making a determination of eligibility or coverage.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You also have the right to request restrictions on disclosure of PHI (Personal Health Information),or alternative means of communication to ensure privacy.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law or by national security activities. This may include disclosing protected health information in the course of judicial or administrative proceedings, in response to a court order or discovery request, or for law enforcement purposes.

For Public Health: We may disclose your protected health information for public health activities and purposed to a public health authority that is permitted by law to collect or receive the information.

In Cases of Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect.

To the Food and Drug Administration: We may disclose your protected health information to a person or company required by the FDA to report adverse events, product defects or problems, or biologic product deviations in order to track products, enable product recalls, make repairs or replacements, or conduct post marketing surveillance, as required.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (Such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Copy of this Notice of Privacy Practices: We are required to follow the terms of this notice. We reserve the right to change the terms of our notice at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain at the time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment.

Access: You have the right to look at or get copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you.

Use and Disclosure: You have the right to authorize or deny any use or disclosure of protected health information not specified in this notice. You may revoke an authorization at any time, in writing, except to the extent that your physician or our office has taken an action in reliance on the use or disclosure indicated in the authorization.

Personal Representative: You may designate a person with the delegated authority to consent to or authorize the use or disclosure of protected health information.

Restrictions and Amendments: You have the right to request us not to use or disclose any part of your protected health information. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care. You may also request that we amend your health information.

Disclosure Accountability: You have the right to request a listing of your protected health information disclosures we have make to entities or persons outside of our office.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have any questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us with the U.S. Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. The Privacy Officer can be contacted by simply contacting the office and asking to speak to the Office Manager who serves as the Privacy Officer.

Signature

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

Your information will be encrypted.