NEW PATIENT INFORMATION FORM

Provider you are seeing:

Dr. Jeffrey C. Houin, Jr.

Dr. Bradley N. Greenhaw

Dr. Ira D. Harber

Jennifer Stone, PA-C

Hannah Savely, PA-C

Date:

Referring Physician:

Phone #:

Patient Information (please print clearly with full detail)

Patient's First Name:

Patient's Last Name:

Patient's Preferred Name:

Middle Initial:

Sex

Male Female

Date of Birth

Social Security #:

Home Phone #:

Work #:

Cell Phone #:

Address:

City:

State:

Zip:

How would you like us to contact you:

Home Work Cell

Leave message on voicemail?

Yes No

Email Address:

Marital Status:

Child Single Married Divorced Other

Ethnicity:

Hispanic Non-Hispanic Decline

Preferred Language:

Race:

Patient's Employer:

Employment Status:

Full Time Part Time Unemployed Retired

Emergency Contact:

Phone #:

Relationship:

Pharmacy Name:

Phone #:

IF PATIENT IS A MINOR

Parent's Last Name:

Parent's First Name:

Middle Initial:

Address (If Different):

City:

State:

Zip:

Date of Birth:

Social Security #:

Phone #:

Relation to Patient:

Mother Father Guardian

Parent's Employer:

Employment Status:

Full Time Part Time Unemployed Retired

INSURANCE INFORMATION

Name of Policy Holder:

Secondary Policy Holder:

Primary Policy Date of Birth:

Secondary Policy Date of Birth:

Relation to Policy Holder:

Child Spouse Other

Relation to Secondary:

Child Spouse Other

Insurance:

Secondary Insurance:

Policy ID #:

Group ID #:

HEALTH HISTORY

Last Name:

First Name:

M.I.:

Height:

Weight:

Name (of Medication):

Dosage:

Frequency:

Add new row

(if you need additional space, please provide on separate sheet of paper)

Medication Allergies (Please list reaction):

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Do you use sunscreen?

Yes No

Family History of Melanoma?

Yes No

Are you Pregnant?

Yes No

Do you have a Pacemaker?

Yes No

Major Medical Surgeries:

Skin Disease History (Please check any of the following conditions you have or have had in the past):

Acne

Actinic Keratosis

Basal Cell Carcinoma

Dry Skin/Eczema

Hay Fever/Allergies

Melanoma

Precancerous Moles

Psoriasis

Squamous Cell Carcinoma

FINANCIAL POLICY FORM

Welcome

Thank you for choosing Dermatology Center of North MS, P.A. for your dermatology needs. We are committed to providing you with quality medical care, our professional fees have been determined through careful consideration, and we believe these fees are reasonable and reflect other area physician's charges. We are pleased to discuss with you any questions you may have concerning your bill. Providing quality care is our primary concern.

Regarding Insurance

PRIVATE INSURANCE POLICIES: Dermatology of North MS, P.A. will file claims directly with your insurance carrier for services where covered benefits have been verified. Insurance verification does not guarantee your insurance will pay for services. Payment of co-insurance, co-pays, deductibles or fees for non-covered services, when applicable, is required at the time of service.

CONTRACTED MANAGED CARE PLANS (HMO, PPO, ETC): Each time you make an appointment with a Dermatology of North MS, P.A. physician, it is your responsibility to make sure the physician is currently under contract with your plan and you have obtained the necessary referrals when needed. Verification of your plan benefits/coverage is required. Often this verification requires us to share the reason for your visit with a managed care plan. Payment of co-insurance, co-pays, deductibles or fees for non-covered services, when applicable, is required at the time of service.

We allow 45 days from the date a claim was filed by our office for the insurance company to pay. If the Insurance Carrier has not paid within this time, you are responsible for the entire balance. We will not become involved with disputes between you and your insurance company regarding deductibles, non-covered services, co-insurance, co-payments, coordination of benefits, pre-existing conditions or "reasonable and customary" charges other than to supply factual information when necessary. You are responsible for the timely payment of your account.

MEDICARE TRICARE/CHAMPUS: Dermatology Center of North MS, P.A. does not accept assignment of Medicare Tricare/Champus benefits. You may be asked to sign a waiver to acknowledge your understanding of your responsibility to pay for services not covered by Medicare Tricare/Champus.

MEDICAID: Dermatology Center of North MS, P.A. is not a contracted provider for services for Medicaid only.

MEDICAL/SURGICAL PROCEDURES: I understand that the pricing that is given by the staff of Dermatology Center of North MS, P.A. is an estimate and that there could be additional cost once the claim has been processed by my Insurance Carrier. If processed and is less, a credit will be issued to the account or refunded when requested.

METHOD OF PAYMENT: For your convenience, Dermatology Center of North MS, P.A. will be happy to accept your personal check, cash, Visa, and MasterCard for payment of your medical services. A $35.00 fee will be accessed to your account for all returned checks.

MINORS: The parent(s) or guardian(s) of a minor are responsible for providing current insurance information for the minor and/or payment in full for services provided. Unaccompanied minors must have authorization for medical treatment signed by a parent or guardian and is responsible for current insurance information for self and/or payment in full for services provided

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.

I have read and understand the above terms and conditions and will verify so by giving my signature.

Signature

Date:

Insurance Assignment and Authorization to Release Information

I request payment of authorized insurance company benefits is made on my behalf to Dermatology Center of North MS, P.A. for any services furnished me by that party who accepts assignment/physician.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare/Other Insurance Company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to the above mentioned party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment.

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.

Name/Signiture:

Date:

Acknowledgement Review of Notice of Privacy (HIPAA)

Patient's Name:

Parent/Guardian's Name:

have received a copy of Dermatology Center of North MS, P.A.'s Notice of Privacy Practices for review which explains how my medical information will be used, disclosed and protected.

Signature of Patient (or Parent/Guardian):

Date:

HIPAA Compliance Officer: C. Gambrel, Practice Administrator

Do you authorize Dermatology Center of North MS, P.A. and its designated representatives to release my medical information to my spouse, parent, guardian, or other.

I do authorize.

I do not authorize.

If authorized, please provide name:

Do you authorize Dermatology Center of North MS, P.A. and its designated representatives to release my medical information to my primary care physician.

I do authorize.

I do not authorize.

If authorized, please provide name of Physician:

Patient Record Disclosure

Contact Permission: The HIPAA Privacy Rules give individuals the right to request a restriction on uses and disclosures of their protected health information. In the event that Dermatology Center of North MS, P.A. needs to contact you (the patient) regarding an appointment, lab result, medication, or any other reason, it is permissible to:

Leave a message on an answering machine. (choose one)

Yes No

Speak with authorized entities listed above. (choose one)

Yes No

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 (Parent or Guardian):

Date:

Your information will be encrypted.