New Patient Packet

PATIENT DEMOGRAPHICS

Patient Name:

Address:

City/State/Zip

Age:

Birth date:

Home#:

Cell#:

Email:

SSN#:

Marital Status:

Married Widowed Divorced Separated Single

Gender:

Male Female

Race:

American Indian Asian Black White Other

Ethnicity:

Non-Hispanic or Non-Latino Hispanic or Latino

Employed by:

Occupation:

Emergency Contact:

Relation:

Cell#:

Insurance Co:

Member ID:

Group ID:

Primary Care Physician & Phone Number:

INSURANCE INFORMATION

The insurance card must be presented for insurance filing purposes or the claim will be considered self-pay. The following must be completed in full so that we may process your insurance information correctly. The information supplied below should be for the person who holds the insurance policy. Provided you are the policy holder, or on the policy, please sign at the bottom. A parent or guardian must sign for a minor patient.

Person responsible for insurance:

Birth date:

Sex:

Male Female

SSN:

Address:

Home Phone:

Cell Phone:

Employed By:

Phone:

Assignment and Release

I, the undersigned, certify that I (or my dependent) have coverage with the insurance company with whom I have provided information and presented my insurance card. I assign directly to the providers at Gardens Dermatology all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges necessary to secure all payment of benefits. I authorize the use of this signature on all insurance submissions. I understand that any copayments, co-insurance or deductibles that may be applied by my insurance are my responsibility and payment is to be made at the time of service.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Responsible Party Signature

Relationship to Patient

Date

PATIENT CONSENT for USE and DISCLOSURE of PROTECTED HEALTH INFORMATION

With my consent, Gardens Dermatology may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to Gardens Dermatology’s Notice of Privacy Practice for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Gardens Dermatology reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practice may be obtained by forwarding a written request to the Gardens Dermatology Privacy Office at 11030 RCA Center Drive, Suite 3015, Palm Beach Gardens, FL 33410.

With my consent, Gardens Dermatology may call my home or other designated location and leave a message on my voicemail, or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any issue pertaining to my clinical care, including laboratory results or medications, etc.

With my consent, Gardens Dermatology may send mail to my home or other designated location. These items include but are not limited to carrying out TPO: for example, appointment reminder cards and patient statements.

I have the right to request that Gardens Dermatology restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restriction, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Gardens 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, Gardens Dermatology may decline to provide treatment to me.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Legal Guardian

Print Patient’s Name

Date

With my consent, Gardens Dermatology may release information pertaining to my clinical care including laboratory results to the person(s) listed below.

1.)

3.)

2.)

4.)

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Legal Guardian

Print Patient’s Name

Date

FINANCIAL RESPONSIBILITY AGREEMENT:

I agree to assign insurance benefits to Gardens Dermatology (GD). GD bills all insurance companies that it is contracted with as “network” providers as a courtesy to our patients. I acknowledge full financial responsibility for services rendered by GD and authorize transfer of all unpaid amounts to me, which includes, but is not limited to: Co-pays, Deductibles, Co-Insurance, Pre-existing Clauses, excluded conditions and /or termination of coverage. I agree to pay all legal fees including attorney and court fees, as well as collection costs in the event of the default payment of charges that are my financial responsibility. I further authorize all insurance paymentsto be made directly to GD. Payment is expected at the time of service. GD will file your insurance as a courtesy to you. If your deductible has not been met and /or you are responsible for copayment under your plan, GD expects payment upon such delivery of services and immediately upon the end of your visit. There will be a $35 fee for returned checks.

PATIENT PRIVACY PRACTICES:

Gardens Dermatology is committed to ensuring your Protected Health Information (PHI) remains confidential. Your paper and electronic medical records are safeguarded and released only with your consent, or to your insurance carrier, other medical professionals directly involved with your care, or as required by law. Our Notice of Privacy Practices policy manual, which explains how your medical information may be used and disclosed, is available for your review or you are welcome to have a copy. If you would like to release your PHI to another doctor or facility you will be required to fill out a separate form to request your records.

CONSENT FOR TREATMENT:

I authorize GD to evaluate and treat me or my family member for the dermatologic condition(s) for which I am seeking medical care. I have read and understand the above clinic policies and I further acknowledge that I accept the terms outlined in each of the above policies.

PROOF AND CHANGE OF INSURANCE:

Patients are required to show both proof of insurance and a Government issued photo ID at their initial and subsequent visits. The patient (parent / legal guardian) is responsible for informing our office of any changes in your insurance coverage since your last visit. Please assure that notification is made no later than 24 hours prior to your appointment to avoid having to reschedule your appointment. If you neglect to update your insurance information, then you will be financially responsible for all services and your office visit.

LAB FEES:

You may incur additional charges from providers outside your network for medically necessary procedures done at or outside of our facility that may be part of your treatment plan. This may include pathology and/ or lab fees.

TELEPHONE CONSUMER PROTECTION ACT (TCPA):

I agree that the facility GD or any other collection or servicing agency or agencies retained by the facility (together referred to hereafter as “collectors”) to collect any money that I owe to the facility may contact me by telephone or text message at any number given by me or otherwise associated with my account, including but not limited to cellular/wireless telephone numbers which may result in my incurring fees for the call or text message. I understand, acknowledge, and agree that the collectors may contact me by automatic dialing devices and through pre-recorded message, artificial voice messages or voice mail messages. I further agree that the collectors may contact me using email at any email address I provide to the facility or otherwise associated with my account.

ACKNOWLEDGMENT:

I acknowledge that I have received access to the “Notice of Privacy Practices” for GD.
I have read, understand, and accept the “HIPAA & Release of Medical Information Policy”, “Consent of Treatment”, and “Financial Responsibilities Agreement”.
I hereby authorize GD to release any information requested by the insurance company or companies or respective representatives and act as my agent to secure payment from any and all services rendered.
I understand that I am financially responsible to the physician for any and all charges incurred by myself and /or my dependents.
I understand that no warranty or guarantee has been made to me relative to result in care or medical outcome.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name

Patient / Guardian Signature

Date

Date of Birth:

Pelvic Examination Consent

Effective July 1, 2020, newly enacted Florida Statute Section 456.51 requires written consent by the patient or the patient’s representative prior to any “pelvic examination.” The statute defines “pelvic examination” as “the series of tasks that comprise an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs.”

Appropriate and thorough dermatologic care requires examination of the skin of the genitalia, pelvic and breast areas. This is an important part of checking for signs of skin cancer and other skin conditions. The exam is always voluntary, performed with an assistant in the room, with as minimal contact as possible, and always in a professional and lawful manner.

I understand that examination of the genitalia, including breast, pelvic and rectal areas, is an essential part of a thorough examination. I understand that an exam of the genitalia, including the pelvic, rectal and breast areas, is completely voluntary and that I can decline the exam at any time if I choose. I understand that if I choose to decline the exam, the medical provider will not be able to check, diagnose or treat any conditions that may exist in these areas.

I freely and voluntarily consent to examination of the genitalia, pelvic, rectal and breast area.

I decline examination of the genitalia, pelvic, rectal and breast area. I understand that because I am declining examination of these areas, the medical provider will not be able to diagnose or treat conditions that may exist in these areas.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name

Date of Birth:

Patient / Guardian Signature

Date

Printed Name of Patient Representative /Guardian

Signature of Patient Representative/ Guardian

Date

MEDICAL HISTORY

Hepatitis:

Other:

SURGICAL HISTORY

Joint: Hip

both left right

Joint: Knee

both left right

Other:

SKIN CONDITIONS

Excessive Sweating

Do you wear sunscreen?

Yes No

If yes, what SPF

Do you tan in a tanning salon?

Yes No

Patient Name:

FAMILY HISTORY

Do you have a family history of Melanoma?

Yes No

If yes, which relative(s)?

Other:

MEDICATIONS

Please list (or show us your own printed record) of all prescription and non-prescription medications, vitamins, etc

Pharmacy Name:

Phone:

Do you pre-medicate before any dental orsurgical procedures?

Yes No

No Allergies

(YES) List all allergies

SOCIAL HISTORY

Smoking Status

Never Former Current smoker

# packs per day

#of years

Social History Details

Not sexually active

Drug Use

Alcohol – none

Sexually active with one partner

IV Drug Use

less than 1 drink/day

Sexually active with more than one partner

1-2 drinks / day

3 or more drinks /day

Do you feel safe at home?

Yes No

Drives in daytime

Drives at night

How often do you exercise?

What is your caffeine use?

Other:

Your information will be encrypted.