Demographics Form - English - Sonoma & Napa Valley Dermatology

PATIENT INFORMATION:

First Name:

Middle:

Last:

Gender

Male Female

Address:

City:

State:

Zip Code:

Preferred Phone:

SSN #:

Date of Birth:

Email:

Primary Care Physician:

Who referred you?

Preferred Pharmacy:

Is it okay to leave a detailed voice message?

Yes No

Employer:

Occupation:

INSURANCE INFORMATION

Primary Insurance

Secondary:

Policy Holder:

Relationship:

Date of Birth:

Emergency Contact Information

Do you give us permission to discuss medical information?

Yes No

Name:

Phone #:

PLEASE NOTE OUR BILLING POLICY AND INDICATE YOUR ACCEPTANCE BY SIGNING BELOW: IF YOUR CHECK IS NOT HONORED BY YOUR BANK YOU WILL BE CHARGED $30 FEE BY THE OFFICE. IF YOU CAN NOT KEEP YOUR SCHEDULED APPOINTMENT, WE REQUEST 24 HOUR CANCELLATION NOTICE. WE RESERVE THE RIGHT TO CHARGE A $50 FEE FOR MISSED OFFICE VISITS AND $100 FEE FOR MISSED SURGICAL OR COSMETIC VISITS. IF YOU ARE LATE 10 MINUTES OR MORE FOR YOUR APPOINTMENT, THE OFFICE RESERVES THE RIGHT TO CANCEL YOUR APPOINTMENT AND CHARGE A MISSED APPOINTMENT FEE OF $50 (MEDICAL) $100 (COSMETIC). YOU ARE RESPONSIBLE FOR CHARGES APPLIED TO YOUR DEDUCTIBLE, COINSURANCE, COPAY AND ANY NON-COVERED SERVICES. YOUR COPAY IS DUE ON DATE OF SERVICE. THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT OF BALANCES NOT COVERED BY INSURANCE. YOU AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO SONOMA DERMATOLOGY AND NAPA VALLEY DERMATOLOGY..

CONSENT FOR TREATMENT: BY SIGNING BELOW, I GIVE CONSENT FOR R. MAKALA ANDERS, MD AND/OR KATHERINE WILKENS, PA TO PERFORM AND PROVIDE MEDICAL CARE, TESTS, AND PROCEDURES (BIOPSIES, SURGERY) AS AGREED UPON IN THE BEST INTEREST OF MY HEALTH.

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 Representative

Date

FINANCIAL POLICY: Payment for service is due in full at the time service is provided. For patients with insurance: copayments and deductibles are due at the time of service. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than you anticipated for care. Any care not paid for by your insurance carrier will be the patient’s responsibility.

If you are having financial problems or have a question about your bill, please call the office. We are always happy to review your charges to be sure they are correct and fair. We will work with you to agree on a reasonable payment schedule, if necessary. We know that you want to keep your account in good standing. If no specific arrangements are made, any account 120 days or older will be referred to an outside collection agency.

ASSIGNMENT OF INSURANCE BENEFITS: Please read and initial below:

I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plans, to Sonoma/Napa Dermatology. This assignment will remain in eect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as any original. I understand I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment.

(initials)

Medicare Patients: I request payment of authorized Medicare benefits be made either to me or on my behalf to Sonoma/Napa Dermatology for any services furnished to me by the listed provider. I authorize any holder of medical information about me to release to the Health Care Financial Administration and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature authorizes that payment be made and authorizes release of medical information necessary to pay the claim.

(initials)

PRIVACY POLICY: I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information, I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications. I

I acknowledge that I may request your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practice

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL POLICY STATEMENT AND PRIVACY POLICY. I UNDERSTAND THAT I AM ULTIMATELY RESPONSIBLE FOR ALL CHARGES REGARDLESS OF WHETHER OR NOT COVERED BY INSURANCE. I HEREBY AUTHORIZE RELEASE OF ALL INFORMATION NECESSARY TO SECURE PAYMENT.

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.

PATIENT'S NAME

SIGNATURE:

Date:

Your information will be encrypted.