New Patient Packet

Dear Patient,

Welcome to Fuchs Dermatology. Thank you for filling out this paperwork ahead of time. This makes the check-in process easier for all of us, and we appreciate it. All forms must be completed in their entirety. Please note that the last form is to keep your credit card in our HIPAA encrypted certified system. Please remember to bring your Insurance card(s), a picture Identification, and the credit card you’ve included in this paperwork.

All necessary precautions are being taken to provide the best and safest care to each and every patient. HEPA filters have been installed in all patient areas, plexiglass barriers have been mounted at the check-in counters, and increased sanitation occurs between all patient encounters. Our goal is to provide you with top quality care in a safe environment. In that regard, if you are over the age of 18 or do not require assistance, please come to your appointment alone. We schedule appointments in a manner to accommodate social distancing. Please arrive no earlier than 10 minutes prior to your appointment. If you arrive late, you may be asked to reschedule.

Thank you,
Fuchs’ Staff

Patient Registration

First Name

Middle Initial

Last Name

Nick Name

Street Address

Unit

City

State

Zip Code

Date of Birth

Home Phone

Cell Phone

Work Phone

Call in case of Emergency

Phone

Relationship

Email address

SSN Number

Drug Allergies

Medications

Referring Physician

Referred By Family / Friend

Initial Appointment Date

Preferred Pharmacy Phone

PLEASE CHECK ALL THAT APPLY

I would like the opportunity to have a total body exam to detect any pre-cancerous or malignant skin growths

I am interested in products/techniques for prevention and/or treatment of wrinkles, aging skin or hair restoration

I am either pregnant breast feeding or might become pregnant in the near future.

THIS OFFICE WILL SUBMIT TO THE FOLLOWING HEALTH INSURANCE CARRIERS: MEDICARE, CAREFIRST BLUE CROSS/BLUE SHIELD, AETNA, AND TRICARE. WE DO NOT TAKE MEDICAID. IF YOU HAVE ANY OTHER INSURANCE CARRIER, YOU WILL BE EXPECTED TO PAY AT THE TIME OF YOUR VISIT AND SEEK REIMBURSEMENT FOR SERVICES RENDERED. PAYMENT IS EXPECTED AT THE TIME OF SERVICE FOR ALL COSMETIC SERVICES. IF YOU ARE NOT PREPARED TO PAY AT THE TIME OF SERVICE, PLEASE RESCHEDULE YOUR COSMETIC VISIT. THANK YOU.

Responsible Party

If other, Please specify

Billing Address

Daylight Phone

Primary Insurance Name

Print Your Name As It Appears On Your Insurance Card (Front and back)

Add file

Please upload a file

Effective Date

Please upload a picture of the front and back of your insurance card.

Name Of Subscriber

Date of Birth

Member Identification

Group/Federal Enrollment Code

Copay: $

PRESCRIPTION CARD ID #

RX BIN #

RX PCN #

RX GROUP #

Secondary Insurance Name

Print Your Name As It Appears On Your Insurance Card (Front and back)

Add file

Please upload a file

Effective Date

Name Of Subscriber

Date of Birth

Member Identification

Group/Federal Enrollment Code

Copay: $

Tertiary Insurance Name

Print Your Name As It Appears On Your Insurance Card (Front and back)

Add file

Please upload a file

Effective Date

Print Your Name As It Appears On Your Insurance Card

Effective Date

Name Of Subscriber

Date of Birth

Member Identification

Group/Federal Enrollment Code

Copay: $

PATIENT AUTHORIZATION

I HEREBY AUTHORIZE GLENN H FUCHS, MD, PC TO APPLY FOR BENEFITS ON MY BEHALF FOR COVERED SERVICES RENDERED. I REQUEST PAYMENT FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO THE ABOVE-NAMED PHYSICIAN.

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 Of Subscriber/beneficiary

Date

New Patient History

If other, please specify:

Skin History

Do you wear Sunscreen?

Yes No

What SPF #?

Do you tan in a salon?

Yes No

Family History

Is there a family history of melanoma?

Yes No

If yes, which relatives?

Smoking History

Currently smokes daily Smokes but not daily Former smoker Has never smoked

Review of Systems

Have you recently experienced any of the following

Changing, bleeding or itching mole/lesion

Rash

Itching

Burning Skin

Depression

Problems Healing

Heat or Cold intolerance

Hepatitis C

Frequent nose bleeds

Alerts

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.

Patient Name:

Date:

Acknowledgement of Receipt of Notice of Privacy Practices

Our NOTICE OF PRIVACY PRACTICES provides information about how we may use and disclose protected health information about you. The NOTICE contains a Patient Rights section describing your right under the law. You have the right to review our NOTICE before SIGNING this consent. The terms of our NOTICE may change. If we change our notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information for you is used or disclosed for treatment, payment, and healthcare operations.

By signing this form, you consent, to our use and disclosure of protected health information about you for treatment, payment, and healthcare operations. You have the right to revoke this consent, IN WRITING, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

PROTECTED HEALTHCARE INFORMATION MAY BE DISCLOSED OR USED FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS.
THE PRACTICE HAS A NOTICE OF PRIVACY PRACTICES AND THAT THE PATIENT HAS THE OPPORTUNITY TO REVIEW THIS NOTICE AND RECEIVE A COPY IF REQUESTED BY THE PATIENT OR THEIR REPRESENTATIVE.
THE PATIENT RESERVES THE RIGHT TO CHANGE THE NOTICE OF PRIVACY POLICIES.
THE PATIENT HAS THE RIGHT TO RESTRICT THE USES OF THEIR INFORMATION BUT THE DISCLOSURES WILL THEN CEASE.
THE PRACTICE MAY CONDITION TREATMENT UPON THE EXECUTION OF THIS CONSENT.
THIS OFFICE MAY LEAVE A VOICE MESSAGE REGARDING SCHEDULED APPOINTMENTS ON ANSWERING SYSTEMS.
I HAVE SEEN THIS OFFICE’S NOTICE OF PRIVACY PRACTICES AND CONSENT TO ITS POLICIES.

This consent was signed by

Date

Relationship To Patient (If Other Than Patient)

Patients Name (If Signed By A Representative)

I Give Permission To Release My Medical Information To: (Check All That Apply)

None

Spouse

Family

Specific Person

If specific person, please specify

Credit Card Agreement

Fuchs Dermatology has implemented a new credit card policy. Much like many other businesses such as a hotel or car rental agency, attorneys, etc. we now have a similar policy where we ask for a credit card which may be used later to pay any balance that may be due on your bill. Co-pays are still due at the time of service. At check in, your credit card information will be obtained and kept securely until your insurance(s) have paid their portion and notifies us of the balance due, if any. Your ability to dispute a charge or question your insurance company’s determination of payment will remain unchanged. If you have any questions about our policy, please do not hesitate to ask. By signing below, I authorize Fuchs Dermatology to keep my signature and my credit card information securely on-file in my account. I authorize Fuchs Dermatology to charge my credit card for any outstanding balances when due. If the credit card that I give today changes, expires, or is denied for any reason, I agree to immediately give Fuchs Dermatology a new, valid credit card which I will allow them to charge over the telephone. Even though Fuchs Dermatology is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.

Visa

MasterCard

Discover

American Express

Patient Name

Date of Birth

Name of Card

Last Four Digits of Credit Card Number

Exp. Date

Please fill out information below for any other person(s) you authorize this credit card for

Add Additional Names

Credit Card Holder’s Signature

Date

Frequently Asked Questions

Regarding the Credit Card on File Agreement Do I have to leave my credit card information to be a patient at this practice? Yes. This is our policy and it is a growing trend in the healthcare industry. Insurance reimbursements are declining and there has been a large increase in patient deductibles. These factors are driving offices to either squeeze more patients into shorter periods of time or to stop accepting insurance. We have decided to focus on becoming more efficient in our billing and collections processes instead.

How much and when will money be taken from my account? The insurance companies on average take approximately 2 weeks to process submitted claims. Whatever the allowed amount is, your copay, coinsurance, and deductible are taken into consideration. It simply depends on your individual policy what you may owe. Once the insurance explanation of benefits is received and posted to your account.

How do you safeguard the credit information you keep on file? We use the same methods to guard your credit card information as we do for your medical information. The card information is securely protected by the credit card processing component of our HIPAA compliant practice management system. This system stores the card information for future transactions using the same sort of technology that any online retailer would. We can’t see the card number – only the last four numbers, giving us no way to use the card outside of the billing system. There is no way to export the card information out of our system. The only way to use it is to process a payment in our practice management system.

What are the benefits? It saves you time and eliminates the need to write checks, buy stamps or worry about delays in the mail. It also drives our administrative costs down because our staff sends out fewer statements and spends less time taking credit card information over the phone or entering it from the billing slips sent in the mail, which are less secure methods than us storing the information. The extra time the staff has can now be spent on directly helping the patients, either over the phone, with insurance claims or in person. I always pay my bills on time.

Why do I have to do this? The entire billing process is time consuming and wasteful, and the few patients that we do have to send to a collection agency end up costing a lot of money. Reducing unnecessary costs are essential to allowing us to continue to be an in-network provider with many insurance companies. Nothing is changing about how much you end up paying

What if there is a payment discrepancy or I have other payment questions? Please contact our billing department directly to settle payment discrepancies or for other payment questions. This policy in no way compromises your ability to dispute a charge or questions your insurance company’s explanation of benefits

May I request a statement of services by mail? Yes.

Financial Policy and Payment Arrangements

Welcome to our Practice! We’re happy to have you as a patient. Before your visit, we would appreciate you reading and signing this form regarding our financial policies.

Thank you!

If your insurance is one that we accept and submit to, then we would like you to sign stating that you understand you will be responsible for any amount that your insurance approves but does not pay either by deductible or copay. To reduce hand-to-hand exposure, our policy is to keep your credit card on file. It is triple encrypted and secure.

COSMETIC PROCEDURE/PRODUCTS ARE NOT COVERED BY INSURANCE. BALANCES FOR THESE SERVICES ARE EXPECTED AT THE TIME OF SERVICE. PLEASE SCHEDULE YOUR ELECTIVE PROCEDURE ACCORDINGLY. If you have a copay for your office visits, you will be required to pay for that at the time of each visit.

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

Consent

During your visit, the dermatologist may need to perform cryosurgery or a skin biopsy, or excision to treat or evaluate your skin condition. Please review and sign the consent form below. You will be given ample time to discuss the procedure if the doctor determines cryosurgery or a biopsy is necessary. This will serve as a standing consent for this and any future treatments, however verbal consent will always be obtained prior to any treatment.

PURPOSE

A biopsy is a surgical procedure used to obtain a sample of tissue for microscopic examination to aid the physician in diagnosis. The entire lesion may not be removed in this procedure. Further medical or surgical treatment may be needed when the diagnosis is made.
Cryosurgery is the use of liquid nitrogen to freeze the skin lesions that respond well to sub-zero temperatures. The process freezes potential skin cancers known as actinic keratosis or solar keratosis. The treatment is also used to freeze the virus infections that cause many common warts.

PROPOSED TREATMENT

I understand that a biopsy requires obtaining a sample of tissue and is a surgical procedure. As in any surgical procedure, there are certain risks including bleeding, postoperative pain, infection, reactions to sutures, anesthetics or topical antibiotics, and scarring. Although all reasonable efforts will be made to minimize the possibility of these potential complications, no guarantees can be made since many factors beyond the control of the physician (such as the degree of sun damage or patient compliance with post-operative instructions) affect the ultimate healing.A pathologist will examine the tissue obtained in this biopsy procedure. I understand I may receive a separate bill from the pathologist or laboratory for this microscopic examination.

Complications of applying liquid nitrogen to the skin may include:
Irritation
Redness
Temporary discomfort
Blistering
Infection
Permanent loss of pigmentation

After the lesion has been treated, most patients develop a blister or scab that lasts for 1-2 weeks.

CONSENT TO OBTAIN PATIENT MEDICATION HISTORY

I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans and other healthcare providers. The collected information will be stored in my electronic medical record and becomes a part of my personal medical record. It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate.By signing this consent form, you are giving your healthcare provider permission to collect and giving your pharmacy and your health insurer permission to disclose information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.

OTHER ACKNOWLEDGEMENT DISCLOSURE

I understand that I will have the opportunity to discuss my procedure with the physician or other professional who is to perform the procedure and have all my questions answered to my satisfaction.

PHOTOGRAPHIC CONSENT

I AUTHORIZED AND CONSENT TO THE TAKING OF A SERIES OF PHOTOGRAPHS OF THE SURGICAL AREAS FOR THE USE OF DR. FUCHS or DR. SMIRNOV FOR DOCUMENTATION OR EDUCATIONAL PURPOSES.I agree to not photograph or record any part of my procedure during my visit today. This includes by camera, tablet, or cellular device.

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

PRINTED NAME:

SIGNATURE:

Date

Your information will be encrypted.