NEW PATIENT FORM

PATIENT INFORMATION

Photo I.D. and current insurance card(s) are required at the time of your visit

Last Name (Legal):

First Name (Legal):

Middle Initial:

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Number:

Patient's Date of Birth (Required):

Sex:

M F

Email Address:

Employment Status (Select One):

Student Working Retired Disabled

Marital Status (Select One):

Single Married Divorced Widowed

Name of Primary Care Physician:

Were you referred by a physician?

Yes No

Name of Referring Physician:

PERSON RESPONSIBLE FOR PAYMENT

Last Name (Legal):

First Name (Legal):

Middle Initial:

Relationship to Patient (Please select one):

Self Spouse Father Mother Other

If your answer above is other, please specify.

PRIMARY INSURANCE - Please enter name exactly as shown on insurance card

Add another insurance

Initial:

A. DEEMED CONSENT FOR DESIGNATED BLOOD BORNE PATHOGENS & CONSENT FOR MEDICAL CARE: I understand that Virginia law requires health care providers to notify me that Hepatitis Band C or HIV (AIDS) Virus testing on sample of my blood may be done if a health care worker is exposed to my blood or body fluids. I understand that this following notice is to advise me that this is in effect at this facility: As health care providers under the Virginia Acts of Assembly Section 32.1-45.1, whenever any health care worker associated with or working for FDL Dermatology, P.L.L.C. is directly exposed to body fluids of a patient in a manner which , according to the guidelines of the Center for Disease Control, may transmit human immunodeficiency virus or hepatitis B or C, FDL Dermatology, P.L.L.C. will proceed to test the patient through his or her physician and the health care worker(s) who was/were exposed. When a person is tested, FDL Dermatology, P.L.L.C. automatically tests for hepatitis Band C for the safety of all concerned. I voluntarily consent to medical care at FDL Dermatology, P.L.L.C., which may include examination, tests, photographs and treatment by doctors and staff. No promises have been made to me as to the results of this treatment or examination

Initial:

B. FEES & PAYMENTS: I understand that my insurance company may not cover 100% of my bills for service provided, and that I will be responsible for the payment of any remaining balance due. I understand that it is my responsibility to provide FDL Dermatology, P.L.L.C. with appropriate and current insurance information --- and to notify FDL Dermatology, P.L.L.C. immediately upon any changes in my insurance coverage ---to ensure efficient claims billing and payment. In the event that I fail to provide all the necessary and current insurance information, I understand that my insurance company(ies) may deny payment of claims relating in services rendered to me, and I understand that I am responsible for my entire account balance. If I am covered by an insurance company that requires a referral from my primary care physician or carrier, it is my responsibility to obtain that referral authorization prior to my visit and furthermore understand, if a required referral is not obtain, I am responsible for the charges.

I understand that I will be responsible for paying co-payments, deductible, and any fees relating to services rendered that are not fully (or at all) covered by my insurance company(ies). Finally, I understand that my copayments are to be made at the time the service is rendered.

Initial:

C. INFORMATION RELEASE: I authorize FDL Dermatology, P.L.L.C. and Courtney Herbert, M.D. to release to my Insurance Carrier any information needed to determine benefits payable to the related services. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to FDL Dermatology, P.L.L.C. and Courtney Herbert, M.D.

Initial:

D. PAYMENT AUTHORIZATION: I authorize insurance payment, if any, directly to FDL Dermatology, P.L.L.C. and Courtney Herbert, M.D. I realize I am responsible for non-covered services/cosmetic

Initial:

E. Medicare: I understand FDL Dermatology, P.L.L.C. and Courtney Herbert, M.D. does not participate with Medicare and I will be billed directly for charges incurred.

Initial:

F. Patient Discharge/Collection Fees: In the event of failure to pay for medical services rendered, I understand that I may be discharged from the services of FDL Dermatology, P.L.L.C. until such time as my account is paid. Additionally, I understand that I may be referred to a collection agency for non-payment of fees due for services rendered by FDL Dermatology, P.L.L.C. I understand that I will be responsible for a 30% collection fee, all agency and attorney fees and costs associated with the collection process (such as court costs), and that these fees and costs will be added to my account balance. I understand that I will be responsible for paying the entire amount of my balance due in addition to the collection agency fee. Further I understand that my PHI will necessarily be revealed in these efforts to collect payment of monies owed.

Initial:

G. Returned Check Fee: I understand that in the event that my check is returned for insufficient funds, I agree to provide cash, money order or certified check for the full amount of the payment owed, in addition to a $30.00 returned check charge.

Initial:

H. Missed Appointment and Cancellation Fee: I understand that I will be assessed a $25.00 fee if I miss an office visit and a $50.00 fee if I miss a surgical or cosmetic procedure without having provided a 24-‐hour advance notice of cancellation.

Initial:

I. Medical Records: I understand that I will be charged a fee to transfer my records to another physician or obtain a copy for myself: $25.00- for charts fifty (50) pages or more in length. This payment is due in full prior to the copying and forwarding of records

Initial:

J. Refill Policy: I understand that it is FOL Dermatology, P.L.L.C. policy and practice to give patients enough medication to sustain them until their next visit; that follow up visit is required for prescriptions that are over one year old; and that depending on the situation, the patient may be given a one-time refill to carry them over until their next follow-up visit.

As the responsible party, I understand and agree to the policies of FDL Dermatology, P.L.L.C. and Courtney Herbert, M.D. as stated in sections a, b, c, d, e, f, g, h, I, and j .

I understand that I am financially responsible for all services rendered.

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 (Parent/Guardian, if patient is a minor)

Date

Medical History

Please fill out this form in its entirety.

Patient's Name:

Date:

Reason for today's visit:

Are you allergic to any medications?

Yes No

If "yes", list below and explain reason

Have you ever had dental anesthesia (Novocaine)?

Yes No

Any adverse reactions?

Yes No

Have you had any lab work done recently?

Yes No

Any abnormal results?

Yes No

If "yes", explain:

List all medications you are currently taking (including prescriptions, over-the-counter meds, vitamins and herbals)

Do you have now, or have you ever had any of the following: (Please select all that apply)

If you selected other, specify.

Gastrointestional:

Nausea

Vomiting

Diarrhea when taking antibiotics

Renal:

Dialysis

Rheumatological:

Arthritis

Endocrine:

Diabetes:

Thyroid

Other

If your answer is Diabetes, please indicate what type.

If your answer is other, please specify.

If your answer is Thyroid, please specify.

Cancer:

Have you had any history of cancer?

Yes No

If "yes", what kind?

List any other diseases or conditions not mentioned:

List surgical procedures you have had in the last 12 months:

Have you seen another dermatologist?

Yes No

If "yes", please list who and when you saw them

When was your last full skin exam?

Do you have a FAMILY HISTORY of the following (if yes select and state who):

Melanoma

Basal Cell Carcinoma

Squamous Cell Carcinoma

Merkel Cell Carcinoma

State who if you have selected any of the above items:

Social History:

Do you drink alcohol?

Yes No

If yes, how many drinks per day?

Do you use IV drugs?

Yes No

If yes, what kind of drugs?

How often do you use them?

Do you smoke?

Yes No

If yes, how much?

Are you a former smoker?

Yes No

Have you had or have you been exposed to HIV?

Yes No

Have you been exposed to Hepatitis B or C?

Yes No

(Women) Are you pregnant?

Yes No

If yes, provide the due date:

(Women) Are you breastfeeding?

Yes No

What is your occupation?

What are your hobbies?

Your preferred pharmacy address:

Your preferred pharmacy phone number:

How did you hear about our office?

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 field

Addendum (H)

Please Read Carefully

Date:

Patient Name:

Primary Insurance:

ID:

Group Number:

Insured's name: (if different from patient)

Relationship to patient:

Insured's Date of Birth:

Insured's employer:

DOES YOUR INSURANCE COMPANY REQUIRE A REFERRAL?

I hereby authorize this physician to apply for benefits for covered services rendered. I further authorize payment of all medical insurance benefits that are payment to me under the terms of my insurance policy, to be paid directly to this physician for services rendered. Additionally, I authorize the release of information needed for processing my insurance. I certify that the information I have reported with regard to my insurance is correct. I understand that it is my responsibility to inform the office of any changes to my insurance or information. Either my insurance company or I may revoke this authorization at any time in writing. I understand that if I have a secondary insurance it my responsibility to submit claims to that company directly.

I hereby certify that the above information is accurate and that I am financially responsible for charges not paid by my insurance company. I also understand that FDL Dermatology has a cancellation/no show policy. I will be billed and agree to pay $25 for office visit appointments and $50 for full body exams, surgical procedures, or cosmetic procedures not canceled at least 24 hours in advance.

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/Responsible party:

Written Acknowledgment Form

I am a patient of FDL Dermatology. I hereby acknowledge receipt of FDL Dermatology's 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:

Date:

OR

I am a parent or legal guardian of [Patient Name]. I hereby acknowledge receipt of FDL Dermatology's Notice of Privacy Practices with respect to the patient.

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:

Relationship to Patient:

Parent Legal Guardian

Date:

Patient Communication Form

A. Family and Friends. It is the office policy of FDL Dermatology not to release confidential medical information regarding your treatment to family members or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (iii) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that that person is entitled to receive information regarding your treatment), (iv) in emergency situations, or (v) other as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you anticipate that you will need or want your medical information to be provided to family members, friends, or caretakers/babysitters, please indicate that below, so that we may best serve you. If you do not want any of your medical information provided to a family member, please check (✔️) the line next to the "no" response. By signing below, you authorize the following people to receive information regarding your treatment or care. (If you wish to add names later on, please confirm this in writing, or call our staff.)

Spouse:

Do you want your medical information to be provided?

Yes No

Parent:

Do you want your medical information to be provided?

Yes No

Add another

B. Alternative Communications. You are also entitled to specify alternative, reasonable means of communication, if you do not wish to be contacted by us in a certain way.

I hereby request the following means of contact only:

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

Patient/Parent/Guardian Signature:

Date:

FOR OFFICE USE
Changes to above authorized by patient over phone :

Add changes

Patient Name:

Email:

Cell Phone Number:

Areas of Interest

(please check all that apply)

Botox

Skin Care Advice/Anti-Aging

Laser Treatment

Age Spots

Chemical Peels

Undereye Circles

Sunscreen Advice

Microdermabrasion

Acne

FDL Dermatology Out-of-Network (OON) Financial Policy

FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT Cash, Checks, Visa, MasterCard, AMEX, Discover.

Out of Network Benefits: We do not accept assignment of insurance benefits for all payers less select BlueCross & BlueShield (BCSS) Policies. We do require you pay what is not covered by your insurance at the time of service. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company. You will be responsible for this process. We will provide you with a Walk-out Receipt, which will display your procedure (CPT) and diagnosis (ICD-l0) codes. This is the extent of our involvement in the process.

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be non-covered
services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance.

Please also be aware that your out-of-network benefits are different from your in-network benefits and likely much higher in terms of your liability. It is highly likely that your benefit levels are lower than what your insurance company would pay, and thus the entire "payable" amount will be applied to your deductible.

In Network Benefits: Regarding Insurance Plans where we are a participating provider. Only select BCSS plans. All co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan where we are not participating providers, refer to above paragraph.

Usual and Customary Rates: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Missed Appointments: Unless canceled at least 24 hours in advance, our policy is to charge $50.00 for missed appointments. Please help us serve you better by keeping scheduled appointments.

Interest and Collections: We reserve the right to charge interest in the amount of 9% as provide by state law. Additionally, for accounts transferred to collections, we do charge a Collections Transfer Fee of 25%.

I have read the financial agreement and understand that I am ultimately responsible for the full debt for services incurred for treatment at FDL Dermatology. My insurance benefits have been explained to me and I fully understand it is my insurance's responsibility to explain what my insurance has verified that they will pay. I also understand verification of benefits is not a guarantee of payment and I am ultimately responsible for any balance with FDL Dermatology.

Thank you for understanding our Financial Policy and fully waive FDL Dermatology for all rights and responsibilities otherwise associated with my claims. Please let us know if you have questions or concerns.

I have read the Financial Policy. I understand and agree to this Financial Policy:

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

Patient Signature:

Date:

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 field

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