New Patient Forms

Date:

Home Phone/Cell Phone:

Last Name:

First Name:

Middle Name:

Email Address:

Street Address:

City:

State:

ZIP:

Sex:

M F

Age:

Birthdate:

Marital Status:

Single Married Widowed Separated

Patient Employed By:

Occupation:

Business Phone:

Spouse Name:

Birthdate:

Business Name:

Occupation:

Business Phone:

Who is responsible for this account?

Relationship to Patient:

Do you have Medical Insurance? If yes, kindly provide additional details by providing the needed information below.

No Yes

Name of Primary Insurer:

Contract #:

Group #:

Subscriber #:

Name of Secondary Insurer (if any):

Contract #:

Group #:

Subscriber #:

Family Physician:

Referring Physician:

In case of emergency, who should be notified?

Phone:

How did you learn of our practice?

PAYMENT REQUESTED AT TIME OF SERVICE - UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical/medical benefits to Zaladonis Dermatology Associates for services rendered by providers in person or under supervision. I understand that I am financially responsible for any balance not covered by my insurance.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Zaladonis Dermatology Associates to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.

MEDICARE - MEDICAID

I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf.

A photocopy of these assignments shall be valid as the original.

Patient:

Date:

HISTORY AND INTAKE FORM

Name:

Date of Birth:

If selected other, kindly specify.

Past Surgical History (check all that apply)

Basal Cell Cancer Surgery

Kidney Transplant

Biological Valve Replacement

Mechanical Valve Replacement

Breast Implants

Melanoma Surgery

Colectomy: Colon Cancer Resection

Ovaries Removed: Ovarian Cancer

Coronary Artery Bypass

Prostate Removed: Prostate Cancer

Gallbladder Removed

PTCA

Heart Transplant

Skin Biopsy

Hysterectomy

Spleen Removed

Mastectomy

Squamous Cell Carcinoma Surgery

Kindly specify:

Right Left Bilateral

TURP

Lumpectomy

None

Kindly specify:

Right Left Bilateral

Other

Joint Replacement, Hip

Kindly specify:

Right Left Bilateral

Joint Replacement, Knee

Kindly specify:

Right Left Bilateral

Joint Replacement within last 2 years

Kidney Removed

Kindly specify:

Right Left

If selected other, kindly specify.

Do you wear sunscreen?

Yes No

If yes, what SPF:

Do you tan in a tanning salon?

Yes No

Do you have a family history of Melanoma:

Yes No

If yes, which relative(s)?

Any other family history:

MEDICATIONS: (Please enter all current medications)

ALLERGIES: (Please enter all allergies)

SOCIAL HISTORY (check all that apply)

CIGARETTE SMOKING:

Never Smoked

Quit: former smoker

Smokes less than daily

Smokes daily

RACE:

White

Black/African American

Asian

American Indian or Native Alaskan

Native Hawaiian/Pacific Islander

ETHNICITY:

Hispanic/Latino

Non-Hispanic/Latino

LANGUAGE:

English

Spanish

PHARMACY:

Name:

Address:

Phone:

Reason for Visit:

HIPAA RELEASE OF INFORMATION

Name

DOB

I authorize the release of information including the diagnosis, medical examination, and claims information rendered to me. This information may be released to and/or my primary care physician

Name

Relationship

Add more

I do not want my information released to anyone other than myself and/or my primary care physician.

PHONE MESSAGES

Please Call:

Home:

Work

Cell

The information provided above may be used by our office staff and an automated reminder call system.
This policy shall remain in effect until terminated by me in writing.

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

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

With my consent, Zaladonis Dermatology Associates may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Zaladonis Dermatology Associates’ Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Zaladonis Dermatology Associates reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy of Practices may be obtained by forwarding a written request to Zaladonis Dermatology Associates, Privacy Officer at 1665 Valley Center Parkway, Suite 120, Bethlehem, PA 18017.

With my consent, Zaladonis Dermatology Associates may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, Zaladonis Dermatology Associates may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

I have the right to request that Zaladonis Dermatology Associates restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Zaladonis Dermatology Associates use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Zaladonis Dermatology Associates may decline to provide treatment to me.

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 of Patient or Legal Guardian

Patient’s Name

Date

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

have received a copy of Zaladonis Dermatology Associates’ Notice of Privacy Practices.

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 of Patient

Date

Your information will be encrypted.