Patient Registration Form

Last Name

First Name

Middle

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Date of Birth

SS #

Email address

Employer Name

Employer Address

Spouse's or Parent's Name

Insured Name

Insured Relationship

Date of Birth

EMERGENCY CONTACT (Other than Household Member )

Name

Phone

Please name who is responsible for authorizing treatment and who will be responsible for the bill.

Name

Relationship

Mailing Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

All Medicare claims are filed by this office, as well as Medicare Supplemental and various PPO/PAR plans. If we do not file your insurance, you will be furnished with a receipt that you can use to file.

Check all Applicable

Medicare

Private

None

Please present all insurance cards to be copied so that they can be kept in your permanent file.

Referred By

FINANCIAL RESPONSIBILITY AGREEMENT

I hereby understand that I am responsible for any and all charges and will pay for these charges at the time the services are rendered unless prior arrangements have been made.

Majors Dermatology retains the right to add a late fee to your balance owed if your account becomes delinquent and is turned over to a collection agency.

Method of Payment:

Cash

Check

Visa / Mastercard

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.

Signature

Date

Assignment of Insurance Benefits

I, the undersigned, hereby authorize the release of any information relating to all claims submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes Michael J. Majors, MD, PA to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though I had personally signed the particular claim. I hereby authorize my insurance company to pay and hereby assign directly to Michael J. Majors, MD, PA all benefits if any. If payment is made to me by my insurance company I will promptly turn payment over to Michael J. Majors, MD, PA. I understand that I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid to Michael J. Majors, MD, PA will be credited to my account, in accordance with this assignment.

Signature

Date

Medicare Authorization

I request that payment of authorized Medicare benefits be made to Michael J. Majors, MD, PA for any health care services provided to me. I authorize any and all health care professional(s) and/or facility(s) to release any of my medical information needed to determine these benefits or the benefits payable for related services to the Health Care Financing Administration and its agents. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "OTHER HEALTH INSURANCE" is indicated in the ITEM 9 box of the HCFA-1500 claim form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes the release of the information to the insurer or agency shown. If Medicare assignment applies, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

Signature

Date

PATIENT /GUARDIAN MUST SIGN THE APPROPRIATE SECTIONS BEFORE SEEING THE PHYSICIAN.

HISTORY AND INTAKE FORM

If Other, Please specify

Do you wear Sunscreen?

Yes No

If yes, what SPF?

Do you tan in a tanning salon?

Yes No

Do you have a family history of Melanoma?

Yes No

If yes, which relative(s)?

Any other family history?

Please enter all current medications and non-prescription medications.

Add Additional Medications

Drug Allergies (please enter all allergies and type of reaction)

Add Additional Allergies

Social History (please check one)

Cigarette Smoking

Never smoked Quit: (former smoker) Smokes less than daily Smokeless tobacco Other

If Other, Please Specify

PHARMACY

Pharmacy Name

City

Zip

Who is your Primary Care Doctor?

Tobacco User

Current Smoker

Former Smoker

Never Smoked

Unhealthy Alcohol Use: Screening & Brief Counseling

How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day?

Influenza Vaccine

Check the one that best fits

Received a flu vaccine this flu season

Did not receive a flu vaccine this flu season because of medical reasons

Did not receive a flu vaccine this flu season because I didn't want one

Did not receive a flu vaccine this flu season

Pneumococcal Vaccine (for patients 65 and older ONLY)

Received a pneumococcal vaccine (Pneumovax)

Did not receive a pneumococcal vaccine (Pneumovax)

Other vaccines (for patients who are EXACTLY 13 years old). If you are not currently 13 years old, please skip this question. Check ALL that apply.

Received one dose of meningococcal vaccine on or between my 11th and 13th birthday

Received one tetanus, diphtheria and pertussis vaccine (TDAP) on or between my 10th and 13th birthday

Received at least three HPV vaccines on or between my 9th and 13th birthday

Advanced Directives
Advance directives are designed to respect your autonomy and determine your wishes about future life-sustaining medical treatment if you are unable to indicate your wishes. Key intervention and treatment decisions are: resuscitation procedures such as Cardiopulmonary Resuscitation (CPR), and mechanical respiration (breathing tube).

Which statement(s) best reflects your wishes on advanced care recommendations?

I want full cardiopulmonary resuscitation efforts to be made (Full Code).

I do not wish to have a breathing tube, even it is necessary to save my life (Do Not Resuscitate).

If my heart were to stop, I do not wish to have chest compressions or an automated external defibrillator to restart my heart, even if its necessary to save my life (Do Not Resuscitate).

I have a living will.

I have a health care proxy whose name is

Name of Health Care Proxy

Contact Number of Health Care Proxy

Patient Signature

Date

Patient Consent For Use and Disclosure of Protected Health Information

With my consent, Majors Dermatology may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

I have the right to review the Notice of Privacy Practices prior to signing this consent. Majors Dermatology reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Majors Dermatology Privacy Officer at 753 S. Washington St., Fredericksburg, Texas 78624.

With my consent, Majors Dermatology may call my home or other designated locations and leave a message on voice mail or in-person in reference to any items that assist the practice in carrying out TPO. This includes appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Majors Dermatology may mail to my home or other designated location any items that assist in carrying out TPO, such as appointment reminder cards and patient statements.

With my consent, Majors Dermatology may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Majors Dermatology restrict how it uses or discloses my PHI to carry out TPO. However, Majors Dermatology, is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Majors Dermatology's use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Majors Dermatology may decline to provide treatment to me.

Name / Signature of Patient or Legal Guardian

Date

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