Patient Registration Packet

Date:

Referred by:

Dr.

Friend

Family

Referred by:

Chart #:

Patient's Name:

First Name:

Middle Name:

Primary Dr:

Date of Birth:

SSS:

Marital Status:

M D S W

Responsible Party:

Same as above

Or:

Relationship:

Street Address:

City:

State:

Zip:

Mailing Address (if different):

Email address:

Primary Phone:

Home Cell

Primary Phone:

Alternate Phone:

Home Cell Work

Alternate Phone:

Employer:

Occupation:

Medical Emergency Contact:

Telephone:

Insurance Information

PRIMARY

Add Secondary Insurance

I understand that my insurance policy is a contract between myself and the insurance company and Affiliated Dermatologists of VA (ADOV) is not a party to that contract. I am ultimately responsible for unpaid balances and non-covered services. I am responsible for informing the office of all changes to my information and insurance PRIOR to my appointments. Insurance must be in force and verifiable at time of treatment. If my insurance company requires a referral, it is my responsibility to obtain one PRIOR to my appointment. If I do not have insurance or a referral, I agree to pay in full at the time of the appointment. I hereby assign all insurance benefits for services rendered, otherwise payable to me, directly to ADOV from Medicare or my private insurance. I authorize ADOV to release medical information to my insurance company, its agents or any third party for use in determining my benefits. If my account enters a delinquent status, I agree to pay all costs of collections including attorney fees and court fees. If my account enters court collection status, I understand that I am no longer a patient of record. I understand that the fee for a returned check is $35. AS A COURTESY ONLY, we will attempt to confirm your appointment prior to the date. ADOV cannot guarantee a reminder call. I understand that ADOV charges a minimum fee of $50 for missed or cancelled appointments, or $100.00 for missed or cancelled surgical appointment without 24 hours notice. I agree to pay such fee. * ADOV will maintain patient records for a minimum of six years following the last visit, barring any exceptions where we may be required to keep them longer.

By signing below I indicate my understanding and agreement with the policies listed above and authorize Affiliated Dermatologists of Virginia to render treatment to the patient named.

DISCLAIMER: 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 Responsible Party:

Date:

Medical HIstory Form

Today's Date:

Patient Name

Date of Birth:

Chart Number:

Local Pharmacy Name & Phone #:

Mail Order Pharmacy Name & Phone #:

REASON FOR TODAY’S VISIT:

ALLERGIES:

Includes medications, anesthetics, latex, foods, etc. Please list name and reaction

MEDICATIONS:

Please list prescription medications, over-the-counter, etc.

MEDICAL HISTORY

OTHER:

SURGICAL HISTORY

Please list type and approximate date(s)

RISK FACTORS:

If you checked Smoke, please specify how much:

If you checked Drink, please specify how much:

If you checked Drugs, please specify:

HIPAA Consent and Required Government Forms

Name:

Date of Birth:

Chart #:

Our notice of Privacy Practices provides information about how we may use and disclose your protected health information. It contains a section on Patient Rights outlining your rights under the law. You have a right to view our Notice before signing this consent. The terms of our Notice may change. If so, you may obtain a copy by contacting our office.

You have a right to request that we restrict how your protected health information is used or disclosed for treatment, payment and healthcare operations. We are not required to agree to such restriction but if we agree, we will honor that agreement.

By signing this form, you agree to our use and disclosure of your protected health information for treatment, payment and healthcare operations. You have a right to revoke this consent, in writing signed by you. Such a revocation will no affect any disclosures already made in reliance upon your prior consent. This form is provided to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient (or responsible party) understands that:

Protected health information may be disclosed for purposes of treatment, payment and healthcare operations, or for other purposes permitted or required by law.
The office has a Notice of Privacy Practices and the patient has the opportunity to review the Notice.
The office reserves the right to change the Notice of Privacy Practices.
The patient has the right to restrict the use of their information but the office does not have to agree to the restrictions.
The patient has the right to revoke this consent in writing and all future disclosures will then cease.

DISCLAIMER: 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:

Self Responsible Party

Signature (Patient or Responsible Party):

Date:

Practice Representative:

Date:

Do you give permission to discuss your medical information with anyone else?

Yes No

If yes:

Add another

May we leave personal medical information on your voice mail/answering machine?

Yes No

If yes, please provide the number we may use to leave the information:

Recent government regulations require that patients be given the opportunity to self-declare their race, ethnicity and primary language. These categories are predefined by the Office of Management and Budget (OMB). Providing this information is voluntary and does not affect the coordination of your care. We understand this information is sensitive and we hope you will find our process as considerate and efficient as possible.

Your information will be encrypted.