Patient Information Form

PATIENT INFORMATION

New Patient

Name Change

Address Change

Insurance Change

THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS:

Last Name:

First Name:

M.I.

Today's Date

Date of Birth:

Age:

Sex:

Male Female

SS#:

MAILING ADDRESS:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

PARENT, SPOUSE, OR RESPONSIBLE PARTY (if different from patient)

Last Name:

First Name:

M.I.

Date of Birth:

INSURANCE COVERAGE

Primary Insurance Co. Name:

Name of Policy Holder (Insured):

Policy Holder (Insured) Date of Birth:

Member ID/Policy #:

Group #:

Secondary Insurance Co. Name:

Name of Policy Holder (Insured):

Policy Holder (Insured) Date of Birth:

Member ID/Policy #:

Group #:

EMERGENCY CONTACT INFORMATION:

In case of Emergency, who should be notified?

Phone:

Relationship to patient:

Do you give our office permission to discuss your medical information with family members?

Yes No

If yes, please provide their names and phone numbers below.

Name:

Relationship:

Phone # (day):

Phone # (evening):

May we leave personal medical information on your answering machine or cell phone?

Yes No

May we e-mail personal medical information to you?

Yes No

Preferred pharmacy for prescriptions:

Primary Care Provider:

DERMATOLOGY MEDICAL HISTORY

Patient:

Date of Birth:

Today's Date:

Reason for today's visit:

List any other past or present diseases or conditions:

List any surgical procedures:

If Other is selected, please specify:

Have you ever had skin cancer?

Yes No

Has anyone in your family had skin cancer

Yes No

Do you have a history of any specific skin disease?

Yes No

Do you develop keloid scars after surgery?

Yes No

Do you bleed easily?

Yes No

Have you ever had a pneumonia vaccine?

Yes No

Do you develop skin rashes in reaction to

Medications

Food

Environment

Bandages

Antibiotic Ointment

List all medications you are currently taking (including prescriptions, over-the-counter medications, vitamins, and herbals):

Are you allergic to any medications?

Yes No

If yes, list below:

Have you ever had dental anesthesia (Novocaine)?

Yes No

Any bad reaction?

Yes No

Do you drink alcohol?

Yes No

If YES, please specify drinks per day:

Do you use IV drugs?

Yes No

If YES, what?

How often?

Do you smoke?

Yes No

If YES, how much:

Have you had or have you been exposed to HIV (AIDS) ?

Yes No

Women

Are you pregnant?

Yes No

Due Date:

What is your occupation?

Hobbies?

RECEIPT OF NOTICE OF PRIVACY PRACTICES:

The Health Insurance Portability and Accountability Act (HIPAA):

Your rights to your health information:

Get an electronic or paper copy of your medical record
Ask us to correct your medical record
Request confidential communications
Ask us to limit what we use or share
Get a list of those with whom we've shared information
Get a copy of our privacy notice
Choose someone to act for you
File a complaint in you feel your rights are violated

For certain health information, you can tell us your choices about what we share:

You have the right and choice to tell us what family members or friends you would like information shared
We will never share your information for marketing purposes without your written consent
We will never sell your personal information

We typically will use or share your health information in the following ways:

With professionals who are treating you
To run our practice, improve your care, and contact you when necessary
To bill and get payment from health plans and other entities
To help with public health and safety issues
To do research
To comply with the law
To respond to organ and tissue donation requests
To work with a medical examiner or funeral director
To Address workers' compensation, law enforcement and other government requests
To respond to lawsuits and legal actions

Our responsibilities:

We are required by law to maintain the privacy and security of your protected health information
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described her unless you tell us we can in writing.

This is a summary of our Notice of Privacy Practices. If you would like a full copy please notify the front desk.

My signature indicates that I have been given the opportunity to received or review a copy of my physician's Notice of Privacy Practices and understand my rights on how medical information may be used and disclosed, and how I can access my health information.

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 or Responsible Party Name:

Date:

Patient Financial Responsibility Consent Form

Please read the following carefully regarding patient responsibility for payment of your care and services.

Insurance Claims:
Providers at Durango Dermatology participate with most insurance companies, but not all plans under all companies are accepted. In order to avoid unexpected charges, it is the patient’s responsibility to confirm that your particular health benefit plan is contracted with Durango Dermatology. Although we will do our best to guide patients through this process, it is impossible for our front desk to keep abreast of the requirements of the thousands of insurance products that are on the market today. Ultimately it is the patient’s individual responsibility to understand the provisions, limits, and requirements of their individual benefit plan and advise us accordingly. Patients will be responsible for insuring payment for all medical services provided. If a carrier denies payment for services because a plan requirement wasn’t met, services were considered “non-covered”, the plan benefits were exceeded, or treatment was considered medically unnecessary or experimental, patients will be responsible for those charges. Please bring your insurance card to each visit in case there are any changes with your coverage. If there are any financial problems, we will absolutely work with you on a reasonable payment plan so that it is not a deterrent to you obtaining medical care.

Referrals and Authorizations:
As a specialist, some insurance companies (particularly HMOs, VA and Tricare) require that prior to any visit you must obtain an authorization or referral from your primary care physician. It is your responsibility to know if this is required by your insurance, and if so, to obtain the referral. If your insurance company rejects a claim because a valid authorization or referral was not in place, the full cost of the visit will be your responsibility.

Patients Without Insurance:
As a courtesy for our patients, Durango Dermatology has created a self- pay fee schedule which includes a discount from our normal fees. Payment is expected at time of service. If a patient cannot pay in full, please contact our office manager to work out an acceptable payment plan.

Labwork:
There may be times that Durango Dermatology will need to seek outside consults for labwork or pathology. We will do our best to keep you informed when this may happen, but the patient will be responsible for these outside charges.

No Show Fee:
We understand things will come up which may require canceling an appointment. Please call us as soon as possible to let us know if you will have to miss an appointment so that we may fill the appointment slot. We, unfortunately, needed to incorporate a policy and fee due to a high no show rate combined with a long waitlist for appointments. Thank you for your understanding.

Medical/Surgical Appointments: To cancel a medical appointment, you may do so through your appointment text reminders or by calling our office at 970-247-1970. If you are calling outside of business hours, you are welcome to leave a message for our team. Patients who fail to show up for their scheduled appointment, without notice of cancellation, will be charged a $40 no show fee.

Cosmetic Appointments: To cancel a cosmetic appointment, you may do so through your appointment text reminders or by calling our office at 970-247-1970. Due to the nature of these appointments, cosmetic appointments require at least a 48 hour notice of cancellation. If you are calling outside of business hours, you are welcome to leave a message for our team. Patients who fail to show up for their scheduled appointment, without notice of cancellation, will be charged a $40 no show fee.

Billing Questions:
Durango Dermatology has contracted with Dermatology RCM for our billing and collection services. Billing questions should be directed to their office at (407) 335-4900.

I understand the above regarding patient responsibility at the time of service and I do not have any questions at this time regarding payment for the medical 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.

Patient or Responsible Party Name:

Date:

Completed by:

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

Signed by Patient:

Date:

Updated:

Init:

Your information will be encrypted.