Patient Demographic Form

Last Name:

First Name:

Middle Name:

Date of Birth:

Age:

Gender:

Male Female

Social Security Number:

Primary Language:

Address:

Street:

Apt / Unit #:

City:

State:

Zip:

Home Phone #:

Work Phone #:

Mobile #:

Email Address:

Marital Status:

Single Married Widowed Divorced Partnered

Employer Name:

Employer Address:

City:

State:

Zip:

Emergency Contact

Full Name:

Relationship to Patient:

Phone Number:

Primary Care Physician

Last Name:

First Name:

Phone Number:

Referring Physician:

Parent/Guardian

Parent/Guardian Name:

Relationship to Patient:

Daytime Phone:

Alternative Phone Number:

Primary Insurance

Primary Insurace Company:

Subscriber's name if different from Patient:

Subscriber's ID Number:

Group Number:

Subscriber's Date of Birth:

Relationship to Patient:

Secondary Insurance

Secondary Insurance Company:

Subscriber's name if different from Patient:

Subscriber's ID Number:

Group Number:

Subscriber's Date of Birth:

Relationship to Patient:

Patient Medical History Form

Reason for today's visit:

If Autoimmune Diseases was chosen, please specify which type:

If Internal Cancer was chosen, please specify which type:

If Kidney Disease was chosen, please specify which type:

If other, please specify:

Past Skin Disease History (Choose all that apply):

Precancerous spot (Actinic Keratosis)

Atypical or Abnormal Mole (Dyplastic Nevus)

Basal Cell Carcinoma

Squamous Cell Carcinoma

Melanoma

Excessive Scarring (Hypertrophic Scar or Keloids)

Other

None

If other, please specify:

Past Surgical History (Choose all that apply):

Heart Valve Replacement

Joint Replacement

Other

None

If other, please specify:

Social History (Choose all that apply):

Smoking:

No Former Yes

If yes, how many packs/day:

Alcohol:

No Social/occasional drinking only Regular consumption

If Regular Consumption is chosen, how many drinks/day?

Occupation:

Do you have a defibrillator and/or pacemaker?

Yes No

Do you have a family history of melanoma?

Yes No

If yes, which relative(s)?

Any other family history?

Women only, please answer the following:

Are you pregnant?

Yes No

If yes, the expected delivery date is:

Are you breast-feeding?

Yes No

Do you take birth control pills?

Yes No

Name of brand?

Preferred Pharmacy:

Location:

Allergies (please list any allergies and the type of reaction that occurs (i.e. rash, itching, swelling etc.)

Are you taking any blood thinners such as Aspirin, Advil, Ibuprofen, Motrin, Warfarin/Coumadin, Pradaxa, Eliquis, Xarelto, Fish or Krill Oil?

Yes No

If yes, which one:

Patient Medication List

Add Information

I authorize the release of medical information to my primary care physician, referring physician, and/or consultants if needed, and as necessary to process insurance claims, insurance applications, and prescriptions. I also authorize payment of benefits to the physician. I assume the responsibility to notify the office should this information change in the future.

Please list the names of people, if any, our staff can discuss your protected health information with:

Add Information

I acknowledge that the above information is true and correct.

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 or Guardian Signature:

Date:

Patient Acknowledgment and Authorizations

I authorize Premier Dermatology Clinic, LLC to collect health information, conduct examinations, and perform procedures as are medically required to administer treatment and medications as deemed necessary or advisable.

Premier Dermatology Clinic, LLC is hereby authorized to release a complete report of services rendered including history taken, clinical findings, diagnoses, and treatment details for the purpose of receiving payment. Recipients of such information may include, but are not limited to, authorized billing agents, insurance carriers, employer’s workers’ compensation insurance company, other third-party payers, the Social Security Administration under Title XVIII (18) of the Social Security Act, Professional Review Organizations or other Intermediaries responsible for payment of services rendered. The release of information consent may be revoked at any time by providing written notice.

If the release of information is refused, the patient will be held responsible for payment of all charges for services rendered. In consideration of medical services provided by Premier Dermatology Clinic, LLC, I give all rights, title, and interest to the medical/surgical/supply reimbursement in accordance with the terms and benefits of the patient’s insurance policy or other health benefits including Medicare Part B. I remain fully responsible for payment of any and all charges not covered by insurance or Medicare.

Patient Assignment of Benefits

Premier Dermatology Clinic, LLC will bill all primary and secondary insurances, but I am ultimately responsible for payment for the services I receive.

I hereby assign to Premier Dermatology Clinic, LLC any insurance or other third-party benefits available for healthcare services provided to me. I understand that Premier Dermatology Clinic, LLC has the right to refuse or accept the assignment of such benefits. If these benefits are not assigned to Premier Dermatology Clinic, LLC, I agree to forward to Premier Dermatology Clinic, LLC all health insurance and other third-party payments that I receive for services rendered to me immediately upon request.

I understand that my signature requests payment be made directly to the Premier Dermatology Clinic, LLC. I authorize the release of medical information necessary to pay the claim. A photocopy of this assignment is to be considered as the original.

Patient Financial Policy

Co-payments are due at the time of service. Premier Dermatology Clinic, LLC reserves the right to send out specimens to an outside laboratory for pathologic interpretation, special staining purposes, and/or to obtain a second opinion. Premier Dermatology Clinic, LLC is not responsible for any outside facility charges that may be incurred. It is your responsibility to know and understand your specific insurance plan and what benefits are provided. We accept all major credit cards, checks, and cash. Please review Premier Dermatology Clinic, LLC's complete Patient Financial Policy attached for more information.

I have read and agree with the Patient Acknowledgment and Authorizations, Assignment of Benefits, and Financial Policy. I understand the terms and conditions outlined herein as confirmed by my signature below.

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 or Guardian Signature:

Date:

Notice of Privacy Practices

Our practices’ Notice of Privacy Practices provides information about how we may use and disclose your protected health information. The Notice contains a Patients’ Rights section describing your rights under the law. You have the right to review our Notice before signing this consent. A copy is available at the front desk. The terms of our Notice may change at any time. 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 the agreement. By signing this form, you acknowledge that you have been given the opportunity to review our Notice of Privacy Practices and you consent to our use and disclosure of protected health information about you for treatment, payment from your insurance company, 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 based on your prior consent. The practice provides this form in compliance with the Health Insurance Portability and Accountability Act of 1996

I hereby acknowledge that I was offered and/or received a copy of Premier Dermatology Clinic, LLC's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area and that a copy of any amended Notice of Privacy Practices will be available at each appointment. Any questions regarding the Privacy Practices of Premier Dermatology Clinic, LLC should be directed to our Office Manager.

I would like to receive a copy of any amended Notice of Privacy practices (circle one):

Yes No

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 or Guardian Signature:

Date:

Discrimination is Against the Law

Premier Dermatology Clinic, LLC complies with applicable Federal Civil Rights Laws and does not discriminate on the basis of race, color, national origin, age, disability, gender identity, or sex. Premier Dermatology Clinic, LLC does not exclude people or treat them differently because of race, color, national origin, age, disability, gender identity, or sex.

If you believe that Premier Dermatology Clinic, LLC has failed to provide these services or discriminated against in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Office Manager.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Office Manager is available to help you. You can file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights.

Patient Financial Policy

Thank you for choosing Premier Dermatology Clinic, LLC as your healthcare provider. We are committed to your treatment being a positive experience. Please help us maintain accurate records by filling out forms legibly and inform us if any changes need to be updated on your account.

Insurance and Insurance Collection

Please have your insurance card available at the time of service. If you are unable to present an insurance card, or if you are covered by an insurance company with which we are not contracted, we require that you pay for services at the time of service. If we are able to collect payment from your insurance company after you have fully paid your account, we will issue you a refund. We will gladly bill your insurance company, if contracted, as a courtesy. Any balances that your insurance company has not reimbursed or acted upon within ninety (90) days will be transferred to your responsibility. If you wish to dispute a charge, you will have 30 days after our first billing statement is received. After this time period, all charges are considered final and no further modifications will be allowed.

Know Your Plan Benefits – Non-Covered Services Are Your Responsibility

Each insurance company, including Medicare, has different plans, each with different benefits. Your health insurance is an arrangement between you and your insurer, therefore you should understand what services are covered under your specific plan. Please contact your insurance carrier who can assist you with any questions you have related to your own benefits and coverage. All co-payments, co-insurance, and/or deductibles are your responsibility. Co-payments are due at the time of service with no exceptions. This is a requirement of your insurer and our office policy. Federal and State insurance regulations prohibit us from discounting or waiving your assigned co-pay or deductible.

We may decline to see patients for non-emergent visits if co-payments are not made at the time of the visit. In addition, please be aware that Dr. Robert Lee may provide services that may not be covered as a benefit under your specific insurance plan. Your insurance carrier may disallow certain diagnoses or services as medically uncovered, medically unnecessary, or cosmetic. The criteria for medical necessity are at the discretion of the insurance carrier and can change at any time. Patients or Guarantors are financially responsible for any and all services provided that may not be covered by your insurance plan. It is your responsibility to know and understand your specific insurance plan and what benefits are provided.

Some procedures you may undergo at our office will involve removing skin or tissue to be examined under a microscope to determine a diagnosis. The charges for this service are known as Laboratory or Pathology charges and will appear on your bill if performed. There are two separate charges for this service. The physician who looks at the slide and provides his/her interpretation based on those slides is known as the Pathologist. There is a charge for that physician’s professional opinion, which is separate from the charge for preparing the actual slide to be examined. Premier Dermatology Clinic, LLC reserves the right to send specimens to an outside laboratory for special staining purposes, pathologic interpretation, and/or to obtain a second opinion. Premier Dermatology Clinic, LLC is not responsible for any outside facility charges that may be incurred. If you have questions about these lab fees, please contact the lab directly as these fees are not charged by our office.

HMO Plans

Patients with HMO plans who are referred by another provider are responsible for obtaining and bringing proper written authorization prior to their visit. It is your responsibility to verify that they properly authorize your visit and treatment in advance. If no authorization is present, a patient can be seen on a cash basis, but will not be reimbursed for the charges.

Secondary Insurance

Having more than one insurance does NOT necessarily mean that your services are 100% covered. Depending on your specific plan’s benefits, the secondary insurers will pay as a function of what your primary insurer pays. We will bill your secondary insurer as a courtesy. You are responsible for any balances after your insurers have processed our claims.

Medicare

You are responsible for your annual deductible and 20% of the allowable fee for covered services. We will bill any secondary or tertiary insurance you may have once we have been informed that you have such coverage. If any balance remains after your claims have been processed, we will transfer responsibility to you and send you a statement.

Important reminder for Medicare enrollees: If you qualified for Medicare coverage and decided to enroll in a Medicare+Choice/Medicare Advantage plan, you may need to obtain a referral from your Primary Care Physician (PCP) before your visit with Premier Dermatology Clinic, LLC will be covered. Please call the phone number on your insurance card for information on your specific plan.

Minor Patients

The adult accompanying a minor and the minor’s parents or guardians are responsible for full payment for services rendered. If a minor is unaccompanied, consent for treatment and payment arrangements must be provided in advance.

Return Check Fee

There is a $25.00 banking fee imposed for returned checks. This sum is used to offset the fees incurred by Premier Dermatology Clinic, LLC by our bank. Payments must be made within 10 days to avoid collection's actions. Future payments must be made with cash, money order, or credit card.

Collections

Premier Dermatology Clinic, LLC will send you a statement after your insurers have been billed and your insurers have considered your charges. If no payment is received after 120 days, your account may be turned over to a collections agency. A $25.00 late payment/pre-collection fee will be added to your account to offset the administrative costs incurred when accounts are assigned for collection.

Request for Medical Records

A signed release of records form is required at the time of your request. You will be charged $0.25 cents per page copied, plus clerical fees of $25.00. If you request the records to be mailed to you, please note that postage fees are not included, and will be charged separately. The medical records will not be released to you until our fees are paid in full.