Patient Registration Form

Today's Date

First Name

Last Name

M.I.

Patient DOB

Patient SSN

Sex

Male Female

Marital Status

Single Married Other

Other

Address

City

State

Zip

Home Phone

Cell Phone

Email Address

Pharmacy Name and Address

INSURED/RESPONSIBLE PARTY INFORMATION

Relationship to Patient

Spouse

Parent

Guardian

First Name

Last Name

M.I.

Address (if different from patient)

Home Phone

Work Phone

SSN

Birth Date

Employer

DEMOGRAPHICS

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Preferred Language

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Decline

INSURANCE INFORMATION

Primary Insurance Name

Secondary Insurance Name

Primary Doctor/Family Doctor

Referring Doctor

In Case of Emergency Contact

Relationship

Phone Number

ASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees.

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 (Patient or, if minor Signature of parent or guardian)

Date

AUTHORIZATION TO RELEASE HEALTH INFORMATION:

Name

Relationship

Phone

Add new row

AUTHORIZATION EXPIRES (UNLESS OTHERWISE NOTED THIS AUTHORIZATION WILL REMAIN IN EFFECT ONE YEAR FROM THE DATE SIGNED)

Never

Date

DAYSTAR SKIN AND CANCER CENTER staff, have permission to leave messages regarding my medical and/or financial information on my voicemail or cell phone.

Yes

Release the following information:

All Records

Chart Notes

Pathology Reports

Operative Reports

History

RELEASE OF INFORMATION

I understand that:

Once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information.
I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524).
My records are protected and cannot be disclosed without written permission
This Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department

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 Patient or Legal Representative

Date

Relationship to Patient

PATIENT MEDICAL HISTORY

Today's Date

Last Name

First Name

M.I.

Date of Birth

Reason for today's visit

Allergies

NONE/No Known Allergies

Adhesive Tape

Anesthesia

Aspirin

Codeine

Sulfa Drugs

Iodine

Latex

Penicillin

Other

Have you ever had dental anesthesia (Novocaine)?

Yes No

Any bad reaction?

Yes No

FAMILY HISTORY – Please indicate if any of your immediate relatives have had any of the following by placing an check in the appropriate box.

Skin Cancer

Mother

Father

Sibling

Diabetes

Mother

Father

Sibling

Heart Problems

Mother

Father

Sibling

Hypertension

Mother

Father

Sibling

Stroke

Mother

Father

Sibling

Thyroid Disorder

Mother

Father

Sibling

Immunization – Please indicate if you have had any of the following administered and if known list the date.

Flu Shot

Yes No

Date

Shingles

Yes No

Date

Whooping Cough

Yes No

Date

Pneumonia

Yes No

Date

Tetanus

Yes No

Date

SOCIAL HISTORY

Occupation

Retired

Disabled

Do you drink alcohol?

Yes No

How often?

Daily

Weekly

Infrequently

Do you use IV drugs?

Yes No

Do you use tobacco?

Yes No

Smoke

Packs per day

If yes, when did you start?

Surgical History: Please list any hospitalizations, surgeries, fractures or major illnesses you have had.

Add new row

Have you ever been exposed to HIV (AIDS)?

Yes No

(Women) Are you pregnant?

Yes No

Due Date

Have you ever had skin cancer?

Yes No

Do you have a history of any specific skin disease?

Yes No

If yes,

Do you have problems healing?

Yes No

Do you develop keloids (scars) after surgery?

Yes No

Do you bleed easily?

Yes No

Do you use sunscreen?

Yes No

Medical History: Have you ever had any of the following?

When taking antibiotics:

Nausea, vomiting, diarrhea

Yeast Infection

NONE of the problems listed

Medications: List any medications you are currently taking

Financial Policy

Thank you for choosing DayStar Skin and Cancer Center for your medical care. We appreciate that you have entrusted us withyour healthcare and we are committed to providing you with the best patient care possible.

Because healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you better understand your responsibilities as a patient. We will do our best to assist you with understanding your proposed treatment and in answering questions related to submitting your insurance claim for reimbursement.

Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals and/or pre-authorizations. You should be knowledgeable of any deductibles, copayments and/or coinsurance.If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket expenses, and coverage limits.

Insurance Coverage
Please provide us with your current insurance card at the time of each visit and notify us of any changes. We will request a copy of your insurance card to copy and keep on file for our records.

Please be aware of and provide any required referrals or authorizations in advance of the appointment. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification.

Our doctors belong to many insurance plans. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the costs of care. We will help you find out if you have out-of-network benefits and submit a claim to your plan on your behalf.

Co-payments/Co-insurance/Deductibles
You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time of service. We accept cash, personal checks, VISA MasterCard, and Discover.

Other Bills
You may receive Pathology services during your visit and there will be additional charges for these services.

Self-Pay
Self-pay patients are required to pay 100% of the estimated amount due at the time of service.

Non-Medical Fees
Additional fees may apply to the following:
Returned Checks – There will be a $25 fee assessed on returned checks.

Missed Appointments – We require a 24 hour notice of appointment cancellation. Appointments missed that are not previously cancelled will be charged a fee of $25.

Late Arrivals - A patient who arrives more than 15 minutes after his/her appointment is considered a late arrival. A late arrival, not considered to be the responsibility of the Practice, will be registered and worked into the schedule as soon as possible. If the patient is more than 30 minutes late, the appointment may be rescheduled.

Assignment of Benefits and Responsibility to Pay
I hereby assign all medical and surgical benefits to which I am entitled. I hereby authorize and direct my insurance to issue payment directly to Daystar Skin and Cancer Center for medical services to myself and/or my dependents. I have also read and understand the financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.

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.

Print Name of Patient

Signature of Patient (or responsible party)

Date

HIPAA Patient Consent Form

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 rights 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 about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care 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).

The patient understands that:

Protected health information may be disclosed or used for treatment, payment, or health care operations
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
The Practice reserves the right to change the Notice of Privacy Practices
The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
The patient may revoke this Consent in writing at any time and all future disclosures will then cease
The Practice may condition receipt of treatment upon the execution of this Consent.

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.

This Consent was signed by:

Printed Name – Patient

Signature

Date

Relationship to Patient (if other than patient):

Witness:

Printed Name – Practice Representative

Signature

Date

Your information will be encrypted.