New Patient Information Form

Dear New Patient,

Thank you for choosing Dermatology at MidTowne!

To prepare for your upcoming appointment, please fill out the form below at least 1 week prior to your appointment.

Directions to our office may be found on our website at www.midtownederm.com.

Please bring your driver's license (or government-issued ID) and your insurance card(s) to your appointment. A minor patient must be accompanied by a parent or legal guardian.

Note that any identifiable and applicable co-pays will be collected at the time of your visit.

You will receive a call to confirm the date and time of your appointment three business days prior to your scheduled visit. If you are unable to keep your appointment as scheduled, kindly notify our office at least 48 hours in advance. You will be charged a no-show fee if you cancel less than 24 hours prior to your appointment.

If you have any questions or concerns, please feel free to contact our office at (616) 248-8864.

We look forward to your visit!

Patient Information

Please complete this form in its entirety. Feel free to ask one of our staff members for assistance.

Full Name:

Email:

Date of Birth:

Street Address:

City:

State:

Zip:

Birth Gender:

M F Other

Marital Status:

Married Single Widow Divorced

Primary Phone:

Home Mobile Work

Secondary Phone:

Home Mobile Work

May we leave medical information or test results on your voicemail or answering machine?

Yes No

Referring Physician:

Location:

Primary Care Physician (PCP):

Location:

Preferred Pharmacy Name:

Location:

Employment Status:

Employed Not Employed Part Time Disabled Retired Student Other

If other, Please specify:

Emergency Contact:

Phone:

Relationship to Patient:

Spouse Mother Father Other

If other, Please specify:

How did you hear about our office?

Friend/Family Member Physician Internet Newspaper/Magazine Other

If other, Please specify:

Insurance Information

Primary

Insurance Name:

Policy Holder Name:

Date of Birth:

Relationship to Patient:

Self Spouse Mother Father Other

If other, please specify:

Secondary Insurance (if applicable)

Insurance Name:

Policy Holder Name:

Date of Birth:

Relationship to Patient:

Self Spouse Mother Father Other

If other, please specify:

Dermatology at MidTowne, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex

Patient History

Medical History

Other (Please Specify):

Past Surgeries (Please List):

Medications - Please list all present medications, including creams & supplements:

Name:

Dose:

Frequency:

Name:

Dose:

Frequency:

Name:

Dose:

Frequency:

Name:

Dose:

Frequency:

Name:

Dose:

Frequency:

Medication Allergies - Please List:

Food or environment allergies - Please list:

Family History - Please list any medical problems/conditions in family member(s):

Skin Disease History

Other (Please Specify):

Do you wear sunscreen?

Yes No

If yes, what SPF?

Do you currently tan in a tanning salon?

Yes No

Have you in the past?

Yes No

Do you have a family history of Skin Cancer?

Yes No

If yes, which relative(s)?

Which type?

Unsure

Melanoma

Basal Cell

Squamous Cell

Social History

Cigarette Smoking:

Never Smoked Quit: Former Smoker Smoke less than daily Smoke Daily

Alcohol Use:

None Less than 1 drink a day 1-2 drinks a day 3 or more drinks a day

Pregnancy Status (if applicable):

Currently Pregnant Planning pregnancy in near future

Review of Systems

Do you currently have or have you had in the past any of the following?

Allergy to adhesive

Yes No

Allergy to lidocaine

Yes No

Proven allergy to LATEX

Yes No

Premedication for artificial heart valves or joint replacement prior to surgeries

Yes No

Rapid heartbeat with epinephrine

Yes No

Allergy to topical antibiotic ointments

Yes No

Problems with bleeding

Yes No

Blood Thinners

Yes No

Problems with healing

Yes No

Problems with scarring (hypertropic or keloid)

Yes No

Thyroid Problems

Yes No

Artificial heart valve

Yes No

Artificial joints within past two years

Yes No

Defibrillator

Yes No

Pacemaker

Yes No

MRSA (Staph Infections)

Yes No

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

Signature:

Date:

If not patient, name of person completing form:

Relationship:

HIPAA Privacy Notice & Authorizations

Patient Full Name:

Date of Birth:

Full Name (Responsible Party if patient is a minor):

Date of Birth:

Relationship to Patient:

Mother Father Other

If other, please specify:

HIPAA AUTHORIZATION: We must have your permission on file if you wish for us to be able to discuss your medical care and/or billing information with others. Please list the name(s) below of persons we are permitted to talk to and in what capacity. Please be sure to indicate at least one Emergency Contact. Thank you.

Name:

Relationship:

Primary Phone:

Please select

Medical

Billing

Emergency

Name:

Relationship:

Primary Phone:

Please select

Medical

Billing

Emergency

PRIVACY POLICY: The Notice of Privacy Practices is stated below of this form. (A Larger Font copy is available at the front desk.) Your signature indicates you have had an opportunity to review this policy and agree to comply with it.

Initial:

FINANCIAL POLICY: Patients are expected to pay for any identifiable and applicable co-pays at the time of their appointment. Patients who are covered by private, commercial insurance plans that our physicians do not participate with are required to pay one hundred percent (100%) of the bill at the time of service. If they are covered by a plan with which we have a contract, applicable and determinable co-payments and deductibles may be collected at the time of service. Patients are responsible for paying one hundred percent (100%) of non-covered or cosmetic services. Payments for amounts billed to you are due within twenty (20) days of receiving a statement. Your signature indicates your willingness to comply with this policy.

Initial:

INFORMATION RELEASE: I authorize the release of information to my primary care or referring physician, to consultants if needed, and as necessary to process insurance claims, insurance applications, and prescriptions. I authorize payment of medical benefits directly to the physician.

Initial:

AUTHORIZATION FOR CONTACT: You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails. Using any e-mail address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

Initial:

FOR MEDICARE PATIENTS ONLY: I request that payment of authorized Medicare benefits be made on my behalf to Dermatology at MidTowne, PC for any services furnished me by its providers. I authorize the release of information to the Centers for Medicare and Medicaid Services and its agents in order to determine benefits and payment of the claim. If "other health insurance" is indicated, I authorize releasing of the information to the insurer or agency shown. I permit a copy of this authorization to be used in place of the original. I understand I am responsible for co-insurance and deductible amounts as directed by my Medicare carrier. (Dermatology at MidTowne is a participating provider.)

Initial:

ALL PATIENTS: PLEASE SIGN BELOW AS CONFIRMATION OF THE ABOVE AUTHORIZATIONS.

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

Signature:

Date:

Notice of Privacy Practices for Dermatology at Midtowne, PC

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a Federal program that
requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your protected health information ("PHI") is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operation.

Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this is a primary care doctor referring you to a specialist doctor.
Payment means such activities as obtaining re imbursement for services, confirming coverage. billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery.
Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. An example of this would be new patient survey cards.
The practice may also be required or permitted to disclose your PHI for law enforcement and other legitimate reasons. In all situations, we shall do our best to assure its continued confidentiality to the extent possible.

We may also create and distribute de-identified health information by removing all reference to individually identifiable information.

We may contact you, by phone or in writing, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you. You do have the right to "opt out" with respect to receiving fund raising communications from us.

The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

Most uses and disclosure of psychotherapy notes;
Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
Disclosures that constitute a sale of PHI under HIPAA; and
Other uses and disclosures not described in this notice.

You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior authorization.

You may have the following rights with respect to your PHI:

The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of Protected Health Information by alternative means or at alternative locations.
The right to inspect and copy your PHI.
The right to amend your PHI.
The right to receive an accounting of disclosures of your PHI.
The right to obtain a paper copy of this notice from us upon request.
The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

If you have paid for services "out of pocket", in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.

We are required by law to maintain the privacy of your PHI and to provide you the notice of our legal duties and our privacy practice with respect to PHI.

This notice if effective as of 09/2013 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post a copy and you may request a written copy of the revised Notice of Privacy Practice from our office.

You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with the practice and with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

Feel free to contact the Practice Compliance Officer at (616) 248-8864 ext 201 for more information.

(Revised 10/2016) Dermatology at MidTowne, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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