BD Patient Packet

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Welcome to Boswell Dermatology

Please note that our practice consists of two buildings in the same complex.

BOSWELL DERMATOLOGY

5701 N. West Ave | Fresno, CA 93711 559.439.3000 phone | 559.439.3004 fax With: J. Scott Boswell, MD Jared Lund, MD Vivian Young, FNP Kristie Cyrus, FNP Jessica Krigbaum, FNP Christina Stempson, FNP Jordan Cutts, FNP Lea Pisching, FNP Brittney Stanley, FNP

BOSWELL DERMATOLOGY SURGERY CENTER

5709 N. West Ave | Fresno, CA 93711 559.439.3000 phone | 559.439.3004 fax With: J. Scott Boswell, MD Jared Lund, MD Vivian Young, FNP Kristie Cyrus, FNP Jessica Krigbaum, FNP Christina Stempson, FNP Jordan Cutts, FNP Lea Pisching, FNP Brittney Stanley, FNP *Note: While skin cancer surgeries are primarily done at our Surgery Center at 5709 N. West Ave, general dermatology patients are also seen here.

Please give at least 24 hour notice for any appointment changes to avoid a cancellation fee of $75. PLEASE ARRIVE 5 MINUTES PRIOR TO APPOINTMENT TIME NOTED ABOVE. Reminder: Patients under 18 years of age must be accompanied by a parent or guardian. In order to ensure a prompt visit, we ask that you bring the following to your appointment: • Completed Paperwork • Insurance Card • Photo ID • List of current medications • Office visit co-pay Our two offices are located near Bullard and West, just south of the Pavilion West Shopping Center. If you have any questions about your appointment, please contact us at 559.439.3000. Thank you! Boswell Dermatology

Directions to Boswell Dermatology

Traveling South on 41: Take 41 South to the Bullard Ave exit and turn right on Bullard. Take Bullard to West Ave and turn left on West. Turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left. Traveling South on 99: Take 99 South to the Herndon Ave exit and turn left on Herndon. Take Herndon to West Ave and turn right on West Ave. Take West Ave and get into the right hand lane before crossing Bullard Ave. After crossing Bullard, turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left. Traveling North on 41: Take 41 North to the Bullard Ave exit and turn left on Bullard. Take Bullard to West Ave and turn left on West Ave. Turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left. Traveling North on 99: Take 99 North to the Herndon Ave exit and turn right on Herndon. Take Herndon Ave to West Ave and turn right on West Ave. Take West Ave and get in the right hand lane before crossing Bullard Ave. After crossing Bullard Ave, turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left.

PATIENT REGISTRATION INFORMATION

Please complete ALL sections below.

PERSONAL INFORMATION

RESPONSIBLE PARTY INFORMATION

If self, please check box and go to insurance section below.

INSURANCE INFORMATION

Please present all insurance cards and notify us of changes in insurance.

Primary Insurance

Secondary Insurance

PERSONAL REPRESENTATIVE

I authorize the following person(s) to receive or know information regarding my health care. This authorization may be revoked in writing at any time.

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  • I hereby give consent for medical/surgical treatment to the care providers with Boswell Dermatology.
  • I acknowledge that I was provided with a copy of the Notice of Privacy Practices. I have read and understand my rights.
  • I authorize the release of information to facilitate treatment, payment or health care operations.

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.

We’re happy that you have chosen Boswell Dermatology. We are committed to excellence in helping you meet your health care needs and understand that billing/payment for health care services can be a confusing and sensitive topic. Please take the time to review the policies of our practice; we will be happy to answer any questions you may have. Please initial to indicate that you have read each policy.

Insurance: We are contracted with many insurance companies and will gladly bill on your behalf. It is the patient’s responsibility to be sure that we have the correct information and that we are in-network with your insurance. Patients are responsible for co-payment, deductibles and co-insurance. All co-payments must be paid at your appointment per our contract with your insurance. There will be a $10 fee added to your bill should you fail to do so. If you have questions regarding your insurance, please call your insurance company so they may address your questions.

MEDI-CAL: We are not contracted with any Medi-Cal plan. We cannot accept, nor bill, these plans under any circumstance. Furthermore, if you have one of these plans, we will not be able to see you on a cash basis. To do so would jeopardize your health benefits and open our office to penalization by the State.

Deductibles: If you have not met your deductible, it is our policy to collect, at the time of your appointment, for services we know will not be paid by your insurance. We do not guarantee that the amount paid at the time of service settles your bill with us.

Non-Covered Services: Please be aware that there may be services rendered at your appointment that are not covered by your insurance. Hair loss, skin tags, and the removal of benign growths are common conditions that may not be paid by insurance companies; you may receive a bill from our office for these services. Please be aware that anything excised from your body will be sent out to a dermatopathologist and you may receive a separate bill from that office.

Referrals/Pre-Authorizations: It is your responsibility to obtain a current referral/pre-authorization for treatment, should your insurance dictate that one is necessary. In the absence of the appropriate documentation, you agree to accept full responsibility for the charges related to treatment.

Proof of Identification/Proof of Insurance: You will be asked to provide us with a copy of your ID and insurance cards for your chart. Please understand that we are helping to protect your identity as a patient. We are also required to send a copy of your insurance and ID to pharmacies for your prescriptions and a copy must accompany any pathology that may be sent out for testing.

Payment: If you do not have insurance and would like to be seen, we accept cash, check, VISA, Discover or MasterCard; all payments are due at the time of your appointment. A $25 fee will be added to any check that is returned for insufficient funds. Once we have received notification/payment from your insurance company, we will send you a statement. All balances are due upon receipt of the statement. It is never our intent to send a patient to collections for non-payment; please contact the billing office if you have any questions regarding your bill.

No-Show/Late Cancellation/Surgeries: We understand there may be times when you miss an appointment due to illness or emergencies. However, we ask that you call 24 hours prior to your appointment to make changes or cancel your appointment. Please understand that because appointment time slots are valuable, you will be charged a $75 no show/late cancellation fee if you do not give a 24 hour notice. This must be paid before you are scheduled for a future visit. If you are scheduled for any surgical procedure, we require a 72 hour notice to cancel or reschedule. You will be charged a $300 fee if you do not give 72 hour notice.

Consent to Photograph: We will be asking permission to take your photo. Please understand that this is to be used for identification purposes and will aid us in keeping track of areas of concern for future treatment. We WILL NOT publish your photos without your permission. If a provider would like to use a photo to be used for medical education, you will be asked to sign a separate consent form to do so.

  • I have read the policies set forth by Boswell Dermatology. My signature below signifies my understanding and willingness to comply with your policies.

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.

NEW PATIENT MEDICAL HISTORY

How were you referred to our clinic?

Medical History

Past Medical/Family/Social History

Cosmetic Concerns

Review of Symptoms

Mark square next to any symptom or condition you are having:

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 ACKNOWLEDGEMENT FORM

THE NOTICE OF PRIVACY PRACTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY, AS IT EXPLAINS:

  • How this office will use and disclose your protected health information.
  • Your privacy rights with regard to your protected health information.
  • This office’s obligations concerning the use and disclosure of your protected health information.

I acknowledge that I have received a copy of the office Notice of Privacy Practices. I further acknowledge that the office Notice of Privacy Practices is available at the front desk upon request.

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.

Pathology Services:

Please note that you may have a skin biopsy done during your visit, or on subsequent visits, here at our office. The safe and standard practice of medicine is to send your skin specimen to a pathologist (a type of doctor) for interpretation. To keep in line with the standard of care, and because we have your health in our best interests, we must send the specimen to meet the high level of care you deserve. Your biopsy will be interpreted by a board certified dermatopathologist, who are physicians who specialize in microscopic diagnosis of skin disorders. The pathologist who evaluates your biopsy will issue a report to our office listing the microscopic findings along with a diagnosis. We customarily send specimens to the following pathology laboratories: Compass Dermatopathology, Inc. 6605 Nancy Ridge San Diego, CA 92121 Telephone: 858 900-2700 Billing Contact: Sasha Lepes, 858 900-2712 University of California, San Francisco (UCSF) Dermatopathology 1701 Divisadero Street. Room 280 San Francisco, CA 94115 Telephone: 800 497-0244 Special Billing Issues Liaison: Paco De Asis at 415 353-7270 Pathology Associates 305 Park Creek Drive Clovis, Ca 93611 Telephone: 559 326-2800 There are many different insurance plans of varying coverage and complexities, so it is impossible for us to know the anticipated charges or coverage your particular plan will have with each pathology lab. Therefore, before your visit we highly recommend that you call your insurance company to see which of the above pathology groups is covered by your insurance, and what your anticipated cost will be for a pathology read of your skin specimen. This will avoid surprises and unexpected bills on your end. If you have a biopsy done during your visit, please let our staff know which pathology laboratory above (UCSF Dermatopathology or Pathology Associates) is preferred. If you do not specify which laboratory you would like us to use, by default we will generally use UCSF Dermatopathology.

Laboratory Services:

You may be sent for blood work after visits at our office. If this occurs, you will be given a Quest Diagnostics lab order form. We recommend you call your insurance and confirm which local laboratory (Quest Diagnostics, LabCorp, Community Medical Center, St. Agnes, etc.) is covered before going for blood work. This will avoid surprises and unexpected bills on your end.

Imaging Services:

You may be sent for imaging (X-rays, CT scans, MRI's) after visits at our office. If this occurs, you will be given an imaging order form. We recommend you call your insurance and confirm which imaging facility (California Imaging, Advanced Medical Imaging, Community Medical Center, St. Agnes, etc.) is covered before going for your imaging test. This will avoid surprises and unexpected bills on your end. I acknowledge the information presented above regarding pathology, laboratory and imaging services.

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