New Patient Forms

RESPONSIBLE PARTY INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

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.

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.

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.

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:

Thank you for courtesy and cooperation,

Catalina Dermatology

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

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.

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

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.

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.

If signed by personal representative,

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:

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

Patient Medical History

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

FAMILY HISTORY

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

SOCIAL HISTORY

REVIEW OF SYSTEMS

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

Cardiovascular

Gastrointestinal

Genital/Urinary

Musculoskeletal

Neurologic

Respiratory

Skin

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.

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

Your Information. Your Rights, Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
When it comes to your health information, you have certain ights. This section explains your rights and some of ou esponsibilities to help you

GET AN ELECTRONIC OR PAPER COPY OF YOUR MEDICAL RECORD

• You can ask to see or get an electronic or paper copy of our medical record and other health information wi have about you. Ask us how to do this
• We will provide a copy or a summary of your health information. We may charge a reasonable, cost-based fee.

ASK US TO CORRECT YOUR MEDICAL RECORD

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to
• We may say "no" to your request, but we'll tell you why in writing within 60 days

REQUEST CONFIDENTIAL COMMUNICATIONS

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say "yes" to all reasonable requests.

ASK US TO LIMIT WHAT WE USE OR SHARE

• You can ask us not to use or share certain health information for treatment, payment, or our operations.
  We are not required to agree to your request, and we may say "no" if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

GET A LIST OF THOSE WITH WHOM WE'VE SHARED INFORMATION

• You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

GET A COPY OF THIS PRIVACY NOTICE

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

CHOOSE SOMEONE TO ACT FOR YOU

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

FILE A COMPLAINT IF YOU FEEL YOUR RIGHTS ARE VIOLATED

• You can complain if you feel we have violated your rights by contacting us at 520-529-8883.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/oct/privacy/hipea/complaints
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.
• If we intend to use or disclose your substance use disorder records (subject to 42 CFR Part 2) for undraising purposes, you have the right to elect not to receive such communications before we send them

Our Uses and Disclosures

HOW DO WE TYPICALLY USE OR SHARE YOUR HEALTH INFORMATION?
We typically use or share your health information in the following ways

TREAT YOU
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks anothe doctor about your overall health condition.

RUN OUR ORGANIZATION
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services

BILL FOR YOUR SERVICES
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

HOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?
We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/ index.html

SUBSTANCE USE DISORDER RECORDS (42 CFPART 2)

• Use and Disclosure: We may use and disclose your substance use disorder records subject to 42 CFR Part 2 for treatment, payment, and health care operations as permitted by law.
• Prohibition on Use in Legal Proceedings: We are prohibited from using or disclosing your substance use disorder records subject to 42 CFR Part 2 in any civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a court order.

HELP WITH PUBLIC HEALTH AND SAFETY ISSUES
We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone's health of safety

DO RESEARCH
We can use or share your information for health research.

COMPLY WITH THE LAW
We will share information about you if state or federal laws require it, Including with the Department of Health and Human Services If it wants to see that we're complying with federal privacy law.

RESPOND TO ORGAN AND TISSUE DONATION REQUESTS
We can share health information about you with organ procurement organizations.

WORK WITH A MEDICAL EXAMINER OR FUNERAL DIRECTOR
We can share health information with a coroner, medica examiner, or funeral director when an individual dies.

ADDRESS WORKERS' COMPENSATION, LAW ENFORCEMENT, AND OTHER GOVERNMENT REQUESTS
We can use or share health information about you:

• For workers' compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

RESPOND TO LAWSUITS AND LEGAL ACTIONS
We can share health information about you in response to : ourt or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

FOR MORE INFORMATION SEE:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

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 - SPANISH

Sus información. Sus derechos. Nuestras responsabilidades.
Este aviso describe cómo se puede utilizar y divulgar su información médica, y cómo usted puede conseguir el acceso a esta información. Por favor, léalo con atención.

Sus derechos

Usted tiene ciertos derechos cuando se trata de su información de salud. Esta sección explica sus derechos y algunas de nuestras responsabilidades para ayudarlo.

Obtener una copia electrónica o impresa de su historia clínica

• Puede solicitar ver u obtener una copia electrónica o impresa de su historia clínica, o bien de otra información médica que tengamos sobre usted.
  Consúltenos cómo hacerlo.
• Le proporcionaremos una copia o un resumen de su información médica, generalmente dentro de los 30 días posteriores a su solicitud. Podemos cobrar una tarifa razonable en base a los

Solicitar una corrección de su historia clínica

• Puede solicitarnos una corrección de la información médica sobre usted que considere incorrecta o incompleta. Consúltenos cómo hacerlo.
• Podemos decir "no" a su solicitud, pero le informaremos el motivo por escrito dentro de un plazo de 60 días.

Solicitar comunicaciones confidenciales

• Puede solicitar que nos comuniquemos con usted de una manera específica (por ejemplo, al teléfono de su casa u oficina) o que le enviemos la correspondencia a otra dirección.
• Diremos 'si" a todas las solicitudes razonables.

Delimitar la información que nos permite usar y compartir

• Puede solicitar que no usemos o ni compartamos cierta información médica para el tratamiento, pago o gestiones internas. No estamos obligados a aceptar su solicitud, y podemos decir 'no" si esto afectara su atención.
• Si paga la totalidad de un servicio o producto de atención médica en efectivo, puede solicitar que no compartamos con su aseguradora de salud tal información para los efectos de pagos o gestiones internas. Diremos "sí" a menos que nos veamos obligados por ley a compartir esa información.

Obtener una lista de aquellos con los que hemos compartido su información

• Puede solicitar una lista (recuento) de las veces que hemos compartido su información médica durante los seis años anteriores a la solicitud, además de con quién la compartimos y por qué.
• Incluiremos todas las divulgaciones, excepto las relacionadas con el tratamiento, el pago y los procedimientos de atención médica, así como algunas otras divulgaciones (por ejemplo, las que usted nos hubiere solicitado).

Obtener una copia de este aviso de privacidad

• Puede solicitar una copia impresa de este aviso en cualquier momento, incluso si ha aceptado recibirlo electrónicamente. Le proporcionaremos una copia impresa de inmediato.

Elegir a alguien para que actúe en su nombre

• Si le ha dado a alguien un poder notarial médico o si alguien es su tutor legal, esa persona puede ejercer los derechos en su nombre y tomar decisiones sobre su información de salud.
• Nos aseguraremos de que la persona tenga esta autoridad y pueda actuar en su nombre antes de tomar cualquier medida.

Presentar una queja si considera que se violan sus derechos

• Puede presentar una queja si cree que hemos violado sus derechos comunicándose con nosotros al 520-529-8883.
• Puede presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y
• Servicios Humanos de los EE. UU., enviando una carta a 200 Independence Avenue, SW, Washington, DC 20201, llamando al 1-877-696-6775 o visitando.
  www.hhs.gov/ocr/privacy/hipaa/complaints.
• No tomaremos represalias en su contra por presentar un reclamo.

Sus Opciones

Para cierta información de salud, puede decirnos sus opciones sobre lo que compartimos. Si tiene una preferencia clara sobre cómo compartimos su información en las situaciones que se describen a continuación, comuníquese con nosotros. Díganos qué quiere que hagamos y seguiremos sus instrucciones.

En estos casos, tiene el derecho y la opción de decirnos que:

• Compartamos la información con su familia, amigos cercanos u otras personas involucradas en su atención.
• Compartamos la información en una situación de emergencia.
• Incluir su información en un directorio de hospitales

Si no puede decimos su preferencia, por ejemplo, si está inconsciente, podemos seguir adelante y compartir su información si creemos que es lo mejor para usted. También podemos compartir su información cuando sea necesario para disminuir una amenaza grave e inminente para la salud o la seguridad.

En estos casos, nunca compartimos su información a menos que nos dé permiso por escrito:

1. Fines de marketing
2. Venta de su información
3. Mayor intercambio de notas de psicoterapia

En el caso de la recaudación de fondos:

• Podemos contactarlo para recaudar fondos, pero puede decirnos que no lo contactemos nuevamente.

Nuestros Usos y Divulgaciones

¿Cómo usamos o compartimos habitualmente su información médica?
Habitualmente usamos o compartimos su información médica de las siguientes maneras:

Para ofrecerle tratamiento
Podemos usar su información médica y compartirla con otros profesionales que lo estén tratando.
Ejemplo: un médico que lo trata por una lesión le pregunta a otro médico sobre su estado general de salud.

Para gestiones de nuestra organización
Podemos usar y compartir su información de salud para ejecutar nuestra práctica, mejorar su atención y contactarlo cuando sea necesario.
Ejemplo: Utilizamos su información médica para administrar su tratamiento y servicios.

Para facturarie por sus servicios
Podemos usar y compartir su información médica para facturar y recibir pagos de los planes de salud u otras entidades
Ejemplo: Le damos información sobre usted a su plan de seguro médico para que pague por sus servicios.

¿De qué otra manera podemos usar o compartir su información médica?
En ocasiones se nos permite o requiere que compartamos su información de otras maneras, generalmente de modo que contribuya al bien público, como la salud pública y la investigación. Tenemos que cumplir muchas condiciones estipuladas por ley antes de poder compartir su información para estos fines. Para más información, visite: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Registros de trastorno por consumo de sustancias (42 CFR PART 2)

• Uso y divulgación: Podemos usar y divulgar sus registros de trastorno por consumo de sustancias sujetos a 42 CFR Part 2 para fines de tratamiento, pago y operaciones de atención médica según lo permitido por la ley.
• Prohibición de uso en procedimientos legales: Se nos prohíbe usar o divulgar sus registros de trastorno por consumo de sustancias sujetos a 42 CFR Part 2 en cualquier procedimiento civil, penal, administrativo o legislativo en su contra sin su consentimiento por escrito específico o una orden judicial.

Ayudar en materia de salud pública y seguridad
Podemos compartir su información médica para ciertos fines como:

• Prevenir enfermedades
• Ayudar con el retiro de productos
• Informar sobre reacciones adversas a medicamentos
• Informar sospechas de abuso, negligencia o violencia
• doméstica
• Prevenir o reducir una amenaza grave para la salud o seguridad de cualquier persona

Investigar
Podemos usar o compartir su información para la investigación médica.

Cumplir con las leyes
Compartiremos información sobre usted si las leyes estatales o federales lo exigen, incluso con el Departamento de Salud y Servicios Humanos si este deseara verificar nuestro cumplimiento de la ley federal de privacidad.

Responder a las solicitudes de donación de órganos y tejidos
Podemos compartir información médica sobre usted con organizaciones de obtención de órganos.

Trabajar con un médico forense o director de funeraria
Podemos compartir su información médica con un juez de instrucción, médico forense o director de una funeraria.

Respaldar indemnizaciones laborales, aplicación de la ley y otras solicitudes gubernamentales
Podemos usar o compartir su información médica:

• Para reclamos de indemnización laboral
• Con fines de aplicación de la ley o con un oficial del orden público Con agencias de supervisión de la salud para actividades autorizadas por la ley
• Para funciones gubernamentales especiales, como servicios militares, de seguridad nacional y de protección presidencial

Para responder a demandas y acciones legales
Podemos compartir información médica sobre usted en respuesta a una orden judicial o administrativa, o a una citación.

Nuestras responsabilidades

• Estamos obligados por ley a mantener la privacidad y seguridad de su información médica personalmente identificable.
• Le haremos saber de inmediato si se produce un incumplimiento que pueda haber puesto en peligro la privacidad o la seguridad de su información.
• Debemos cumplir con las obligaciones y políticas de privacidad descritas en este aviso y proporcionarle una copia del mismo.
• No utilizaremos ni compartiremos otra información que la descrita aquí a menos que nos lo autorice por escrito. Si nos da su autorización, podrá cambiar de opinión en cualquier momento. Háganos saber por escrito si cambia de opinión.

Para más información puede consultar:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Cambios a los términos de este aviso
Podemos cambiar los términos de este aviso, y los cambios se aplicarán a toda la información que tengamos sobre usted. El nuevo aviso estará disponible a pedido, en nuestra oficina y en nuestro sitio web.

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