New Patient Intake Form

REVIEW OF SYSTEMS

COSMETIC HISTORY

HAVE YOU RECENTLY HAD ANY OF THE FOLLOWING: (please check all that apply)

NEW PATIENT INTAKE FORM

Patient Consent

Consent for Treatment
I hereby consent to and authorize All Dermis Dermatology, PC to initiate my evaluation, diagnosis, and treatment as deemed medically necessary. I authorize All Dermis Dermatology, PC to submit my pathology specimens for evaluation and diagnosis by a pathologist, who may send my slides to another pathologist for a second opinion, or for additional staining, as needed for an accurate diagnosis. I authorize All Dermis Dermatology, PC to submit a claim to my insurance on my behalf, or on behalf of my dependents, for pathology testing. These services may or may not be covered by my insurance plan/program, and I may be responsible for any remaining balance on my account. I authorize All Dermis Dermatology, PC to retrieve my prescription history and import it into my electronic chart.

Consent for Treatment of Minors
I understand that I am legally required to be present for the first visit of my child or any minor under my care, under the age of 18. I hereby authorize All Dermis Dermatology, PC, and its physicians and staff to continue the evaluation, diagnosis, and treatment of my child, dependent or foster child without my presence in the office after the first visit. I consent to in-office procedures for my dependent minors that include, but are not limited to, cryotherapy, cautery, biopsies, and injections. I understand that while this authorization shall remain in effect, effective immediately and indefinitely, I may revoke this authorization at any time and for any or no reason by submitting a written request to the office.

Consent for Filing Insurance Claims
In the event that All Dermis Dermatology, PC participates in my insurance plan, I hereby authorize All Dermis Dermatology, PC to file claims and appeals on my behalf, and on behalf of my dependents, and to receive benefits directly from my insurance company, Medicare and/or supplemental policy, although I realize that All Dermis Dermatology, PC, is currently a direct pay practice and does not participate in most, if not all, insurance plans (including Medicare/Medicaid/TriCare). I certify that I am currently am not a recipient of Medicare/Medicaid/TriCare or any other state or federal government health insurance program and will not submit claims to Medicare/Medicaid/TriCare (or supplemental insurance) for services rendered at All Dermis Dermatology, PC. I also authorize the release of any medical information to my insurance company/program that is necessary for the processing of claims. I understand that my signature will remain on file for the timely submission of insurance claims and for the release of my medical information to my insurance company/program.

Consent for Photography and Videography
I hereby consent to and authorize All Dermis Dermatology, PC and Dr. Derek V. Chan, MD, Ph.D. to take, use and disclose my photographs, videos, treatment successes in stages, that constitutes Protected Health Information (PHI), in electronic or digital form or otherwise, to his social media pages, prospective patients, and such other means as may be necessary for marketing and educational purposes, without further limitation, for a duration determined at the discretion of Dr. Derek V. Chan, MD, Ph.D., including after completion of my treatment. I hereby waive all claims for compensation or damage for such use and disclosure that are consistent with this authorization. I understand that I am under no obligation to provide my authorization and that my treatment, payment, enrollment, or eligibility for benefits will not be impacted in any way by my refusal to provide such authorization. I understand that while this authorization shall remain in effect, effective immediately and indefinitely, I may revoke this authorization at any time and for any or no reason by submitting a written request to the office.

Consent for Appointment Reminders, Phone calls, and Emails
I hereby consent to and authorize All Dermis Dermatology, PC to send me notifications and appointment reminders via text messages, phone calls, and/or emails. I understand that messaging and data rates may apply according to my cellular plan. I understand that I am not obligated to receive, or continue to receive these communications, and may unsubscribe at any time by submitting a written request to the office.

Consent for Communication of Protected Health Information (PHI)
I hereby consent to and authorize All Dermis Dermatology, PC to communicate disclose my PHI including medical diagnoses, treatment, biopsy/pathology/lab results, and insurance claims information to the individuals authorized above. I authorize All Dermis Dermatology, PC, and its agents and employees to leave a voicemail at my preferred number with test results. I understand that while this authorization shall remain in effect, effective immediately and indefinitely, I may revoke this authorization at any time, and for any or no reason, by submitting a written request to the office.

By signing below, I certify that above information I have entered is true. I acknowledge that I have read, understand and agree with the office policies, consents, and notice of privacy policy, and all my questions have been answered to my satisfaction

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

Office Policy

Notice of Privacy Practices
I acknowledge that I have received, read, and understand the Notice of Privacy Practices, which explains how information about me can be used and disclosed by the practice. Any and all of my records, in written, oral or electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law. I have the right to restrict or revoke this consent anytime, in writing, except where disclosures have been made in accordance with my prior consent.

I hereby authorize All Dermis Dermatology, PC to use and disclose any medical information necessary for evaluation and treatment and for submission or verification of insurance claims and appeals on my behalf.

Financial Policy

✓ Payment is expected and required in full at the time services are rendered. Checks are not accepted at this time for payment

✓ Insurance coverage is a contract between me and my insurance company and is not a guarantee of payment. Currently, All Dermis Dermatology, PC, as a direct pay practice, is out of network with most (if not all) insurance carriers. In the event that start participating in my insurance plan, I remain responsible for obtaining any required referrals prior to the visit, otherwise I am responsible for payment of balance at time of visit. I understand that, regardless of coverage, I am responsible for any remaining balance not covered by my insurance policy/policies for all charges for services rendered to me or to my dependents at All Dermis Dermatology, PC. It is my responsibility to contact my insurance plan if I have questions regarding my benefits and coverage. As previously noted, I realize that All Dermis Dermatology, PC, is currently a direct pay practice and does not participate in most, if not all, insurance plans (including Medicare/Medicaid/TriCare). I certify that I am currently am not a recipient of Medicare/Medicaid/TriCare or any other state or federal government health insurance program and will not submit claims to Medicare/Medicaid/TriCare (or supplemental insurance) for services rendered at All Dermis Dermatology, PC. I also authorize the release of any medical information to my insurance company/program that is necessary for the processing of claims.

✓ I understand that All Dermis Dermatology, PC, is primarily a direct pay practice. As such, All Dermis Dermatology, PC does not participate in many insurance plans. However, in the event that All Dermis Dermatology, PC does participate in a particular insurance plan or government program (e.g. Medicare/Medicaid/TriCare/supplemental programs), All Dermis Dermatology, PC is required by contract with commercial insurance companies as well as government health programs to collect any copayment, co-insurance and any unmet deductible at the time of service. The amount collected at the time of service is an estimate based on benefit information available. Specific benefit amounts are unavailable until claims have been filed and/or processed by the companies. Patient portion is adjusted and refunds/amounts due are reflected in patient account after claim processing is complete.

✓ I understand that biopsies and other surgical procedures will result in two charges. First charge is by the provider for performing the biopsy and collection of specimen for submission for pathology. A second charge is by the pathologist (a medical doctor chosen by All Dermis Dermatology, PC) for processing and examining the submitted specimen. I understand that I will be billed separately by the pathologist who will render histopathological diagnosis.

✓ I understand that I will communicate the preferred lab for my insurance company/program for all blood work at the time of service

Medical Record Copies
I acknowledge that there is a fee for obtaining copies of my medical records, $20 for the first 100 pages, and for each additional 100 pages.

Medical Record Copies
I acknowledge that there is a fee for obtaining copies of my medical records, $20 for the first 100 pages, and for each additional 100 pages.

Cancellation and Late-Show Policy
I acknowledge that I have received, read, and understand the Cancellation and Late-Show Policy. This policy requires that I call the office at least 24 hours prior to cancel my scheduled appointment or I will incur a $50 cancellation fee. Additionally, if I am more than 15 minutes late for my appointment, I may be asked to reschedule my appointment. Certain types of appointments and procedures may require a deposit, which may be applied towards the cancellation fee if I fail to cancel within 24 hours.

Treatment Compliance Policy
I acknowledge that I am not eligible for refills of any topical, oral, or systemic medications in the event that I miss or cancel my appointments. Some treatment plans require regular clinical or lab monitoring for the development of side effects, some with serious consequences, so follow-ups are scheduled to ensure that my treatment plan is effective as well as safe.

Cosmetic Services and Retail Products
All Dermis Dermatology, PC will charge in full for cosmetic services and products at the time of service. Unless defective due to manufacturing errors, I understand that there are no exchanges or refunds on cosmetic retail products.

Audio and Video Recording Policy
I acknowledge that to maintain confidentiality and privacy of other patients, visitors, staff, and physicians at the practice, I am strictly prohibited from using any audio or video recording devices, including but not limited to cameras, cell phones, portable audio or video recorders, or recording apps, on the premises of All Dermis Dermatology, PC, including in the exam rooms or waiting areas. I will turn my phone off or on silent mode while in the exam room.

By signing below, I certify that above information I have entered is true. I acknowledge that I have read, understand and agree with the office policies, consents, and notice of privacy policy, and all my questions have been answered to my satisfaction. By typing my name below, I am signing this application electronically. I agree my electronic signature is the legal equivalent of my manual signature on this form.

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