BD Patient Packet

Welcome to Boswell Dermatology

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

Boswell Dermatology is located on West Ave, south of Herndon, inside the West Park Professional Centre.

If you have any questions about your appointment, please contact us at 559.439.3000.

Thank you!
Boswell Dermatology

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.”

While no physician takes compensation for prescribing medications, our physicians teach other physicians about the medications and are therefore compensated.

PATIENT REGISTRATION INFORMATION

Please complete ALL sections below.

PERSONAL INFORMATION

Marital Status:

Single Married Divorced Widowed

Sex:

Male Female

Today's Date:

Last Name:

First Name:

Middle Initial:

Maiden Name:

Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Date of Birth:

Social Security Number:

Email Address:

RESPONSIBLE PARTY INFORMATION

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

Responsible Party:

Self Spouse Parent

Sex:

Male Female

Spouse/Parent Name:

Date of Birth:

Billing Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

INSURANCE INFORMATION

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

Primary Insurance

Secondary Insurance

Primary Insurance:

Secondary Insurance:

ID #:

Group #:

Insured Name:

Insured DOB:

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.

Name:

Phone Number:

Add new row for another representative

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.

Patient Signature (or Responsible Party Signature):

Date:

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.

Initials:

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.

Initials:

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.

Initials:

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.

Initials:

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.

Initials:

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.

Initials:

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.

Initials:

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.

Initials:

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.

Initials:

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.

Patient Signature (or Responsible Party Signature):

Date:

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

Name:

Date:

Age:

How were you referred to our clinic?

Physician (full name): Dr.

Did the same requesting physician see you for your skin condition?

Yes No

Friend (name):

Other (please specify):

Pharmacy Name:

Phone:

Medical History

In your own words, please state the reason for your visit (chief complaint):

How long have you had this problem? (duration)

What parts of your body are affected? (location)

What makes it better? What makes it worse? (change in severity)

How does this problem bother you? (symptoms)

What treatments have you received for this problem? (previous therapy)

Is your problem (timing)

worsening?

stable?

improving?

Explain:

Past Medical/Family/Social History

Please list all past major illnesses and operations:

Please list all medications you are currently taking:

Please list all drug and environmental allergies:

Is there a family history of a condition similar to yours?

Yes No

Additional Information:

Occupation:

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Cosmetic Concerns

Would you be interested in anti-aging/wrinkle treatment?

Yes No

Would you consider Botox/Juvéderm filler?

Yes No

Are you interested in laser hair removal?

Yes No

Review of Symptoms

Skin: Have you seen a doctor for other skin problems?

Yes No

Which one(s)?

Do you have (please mark square(s) that apply:

hair loss

skin cancer

abnormal moles

When you are exposed to sunlight, do you:

1. Always burn

2. Usually burn, rarely tan

3. Often burn, tan slowly

4. Sometimes burn, tan well

5. Rarely burn, always tan

6. Never burn, deeply tan

Women: Are you pregnant?

Yes No

Do you plan to become pregnant?

Yes No

Are you nursing?

Yes No

Do you have breast problems?

Yes No

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

General

fever

chills

weight loss

loss of appetite

fatigue

Cardiovascular

pacemaker

heart disease

mitral valve prolapse

hypertension

chest pain

Respiratory

cough

difficulty breathing

lung disease

tuberculosis

coughing up blood

Genitourinary

kidney disease

bladder disease

blood in urine/dark urine

female problems

stillbirth/spontaneous abortion

problems with urination

Musculoskeletal

joint aches

swollen joints

muscle aches

muscle weakness

back pain

ankle swelling

fingers sensitive to cold

Psychiatric

nervous breakdown

depression

insomnia

Endocrine

diabetes

enlarged glands

hormonal problems

thyroid disease

Hematologic/Lymphatic

anemia

free bleeding tendency

Immunologic

immune deficiency

frequent infections

If needed, please elaborate on any of the above:

Patient Signature (or Responsible Party Signature):

Date:

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.

Patient or Patient Representative Signature:

Date:

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.

Name:

Date:

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