CHARLES R. PAULY, MD
BLUE RIDGE DERMATOLOGY, PC
CYNTHIA H. DENT, MD PAUL A. KRUSINSKI, MD
KEITH A. KNOELL, MD INES W. SOUKOULIS, MD
JANE M. LYNCH, MD
PATIENT INFORMATION – PLEASE PRINT NAME____________________________________________________________________________________ AGE ___________________ (LAST)
(FIRST)
(MIDDLE)
SEX: M F (CIRCLE) DATE OF BIRTH__________________________
SOCIAL SECURITY NUMBER_________________________
PERSON RESPONSIBLE FOR ACCOUNT __________________________ SOCIAL SECURITY NUMBER_________________________ MAILING ADDRESS _______________________________________________________________________________________________ __________________________________________________________________________________________________________________ (CITY)
(STATE)
(ZIP CODE)
HOME PHONE_________________________ WORK PHONE_________________________ CELL PHONE_________________________ IF MAILING ADDRESS IS A POST OFFICE BOX - PLEASE GIVE PHYSICAL ADDRESS HOME PHYSICAL ADDRESS_________________________________________________________________________________________ FAMILY DOCTOR_______________________________________________ FAMILY DOCTOR PHONE___________________________ DID A DOCTOR SUGGEST YOU MAKE THIS APPT? MARITAL STATUS:
SINGLE
EMPLOYEE STATUS:
FULL-TIME
STUDENT STATUS:
FULL-TIME
MARRIED
YES
NO
REFERRING DOCTOR: ___________________________
WIDOWED
DIVORCED
SEPARATED
PART-TIME
NOT EMPLOYED
SELF EMPLOYED
RETIRED
PART-TIME
NOT A STUDENT
INSURANCE COMPANY (1)__________________________________________
DISABLED
(2)_________________________________________
INSURANCE POLICY HOLDER’S NAME (1)______________________________ (2)__________________________________________ POLICY HOLDER’S DATE OF BIRTH (1) _________________________________ (2) _________________________________________ EMERGENCY CONTACT PERSON______________________________Relationship:_________________PHONE___________________ PATIENT’S EMPLOYER _____________________________________________________
EMPLOYER’S PHONE _________________
PARENT’S / GUARDIAN’S EMPLOYER ________________________________________
EMPLOYER’S PHONE _________________
CONSENT In order to receive treatment from the physicians of Blue Ridge Dermatology, PC, you must read and sign the following: Privacy – The medical information gathered and created about you or your minor child will be used for treatment, payment and medical operations. Our office maintains strict, privacy guidelines concerning the use of your personal health information. You can receive a copy of our policy upon request. You may ask for restrictions to be placed on release of personal medical information, although Blue Ridge Dermatology may not agree to these restrictions. SIGNATURE AUTHORIZATIONS I, the undersigned, authorize Charles R. Pauly, MD, Cynthia H. Dent, MD, Keith A. Knoell, MD, Jane M. Lynch, MD, Paul A. Krusinski, MD or Ines W. Soukoulis, MD to provide medical care to me or my minor dependent. I, the undersigned, authorize release of any medical information or other information necessary to process insurance claims for myself or my minor dependent. I, the undersigned, request that payment of authorized Medicare and/or other insurance benefits be made, for me or on my behalf, to Blue Ridge Dermatology, PC, for any services furnished by that physician/provider. I authorize any holder of medical information about me to release to my insurance carrier and/or the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable for related services.
SIGNATURE: _________________________________________________________________________ DATE:_____________________________ ANNUAL VERIFICATION OF INFORMATION
______________________________________ SIGNATURE
_____________________ DATE
______________________________________ SIGNATURE
__________________ DATE
______________________________________ SIGNATURE
_____________________ DATE
______________________________________ SIGNATURE
__________________ DATE
**PLEASE TURN OVER THIS PAGE AND FILL OUT MEDICAL INFORMATION QUESTIONS**
MEDICAL HISTORY INFORMATION
NAME:______________________________ CHART #:_________________
CHIEF COMPLAINT - Describe symptoms or conditions for which you are seeing the doctor: DATE OF VISIT: ________________ COMPLAINT: _________________________________________________________________________ _________________________________________________________________________________ DATE OF ONSET: _________________ DATE OF VISIT: ________________ COMPLAINT: _________________________________________________________________________ _________________________________________________________________________________ DATE OF ONSET: _________________ DATE OF VISIT: ________________ COMPLAINT: _________________________________________________________________________ _________________________________________________________________________________ DATE OF ONSET: _________________ DATE OF VISIT: ________________ COMPLAINT: _________________________________________________________________________ _________________________________________________________________________________ DATE OF ONSET: _________________
FEMALE PATIENTS – ARE YOU PREGNANT, NURSING, OR CONTEMPLATING PREGNANCY AT THIS TIME? YES
NO
PREVIOUS ILLNESS: (CHECK) None of the listed _________
_____ High Blood Pressure _____ Liver Disease/Hepatitis _____ Heart Disease _____ Seizures _____ Bleeding Disorders _____ Inflammatory Bowel Disease _____ Stroke _____ Diabetes _____ Blood Clots _____ Arthritis
_____ Psoriasis _____ Herpes Simplex _____ Varicose Veins _____ Depression _____ HIV/AIDS _____ Leg Ulcers
_____ Eczema/Allergies/Asthma _____ Basal Cell Carcinoma _____ Squamous Cell Carcinoma _____ Melanoma _____ List Any Other Cancers _____ End Stage Renal Disease
LIST ANY OTHER SERIOUS DISEASE: ______________________________________________________________________________________________________________________
Ever had a blood transfusion? YES Chest X-Ray in the past 2 years? YES Have you had an organ transplant? YES
NO Are you taking Aspirin or Coumadin? YES NO NO APPROXIMATE DATE: ____________________________ NO Do you take antibiotics before surgery or dental work? YES NO
SOCIAL HISTORY: What is your occupation? _________________________________________________ Do you smoke? YES NO FREQUENCY ________________________________________________ Do you consume alcoholic beverages? YES NO FREQUENCY ________________________________ FAMILY HISTORY (Check any that apply). _____Asthma _____Seasonal Allergies
_____ Melanoma
_____Eczema
_____Psoriasis
FINANCIAL RESPONSIBILITY AND AUTHORIZATION FOR PAYMENT I understand that I am financially responsible for payment for services rendered by Blue Ridge Dermatology, PC. I authorize Blue Ridge Dermatology, PC to provide medical care and to release records and/or medical information for the purpose of insurance claims. I assign payment and/or benefits of said claim(s) directly to Blue Ridge Dermatology, PC. I understand that all charges not paid by my insurance carrier(s) remain my responsibility. I understand that I am able to restrict the personal health information shared with third-party insurers and health plans if I pay for the service in full on the day rendered. I agree that, in order for Blue Ridge Dermatology, PC to service my account or to collect any amounts I may owe, Blue Ridge Dermatology, PC may contact me by telephone at any telephone number associated with my account. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing device, as applicable. I understand that if my account is not paid in full, it will be recommended for collections and a $20 collection exertion fee will be added to the account. (For all patients under the age of 18, a parent or guardian must authorize medical treatment and accept responsibility for payment by signing.) SIGNATURE: _________________________________________________________________________ DATE:_________________________ ANNUAL VERIFICATION OF INFORMATION ______________________________________ SIGNATURE
__________________ DATE
______________________________________ SIGNATURE
_______________ DATE
______________________________________ __________________ SIGNATURE DATE
______________________________________ SIGNATURE
_______________ DATE
CURRENT MEDICATION LIST BRING THIS LIST WITH YOU
Patient Name: _________________________________ DOB: _______________________ Chart #: _____________________
Dr. Pauly Dr. Dent Dr. Knoell Dr. Lynch Dr. Krusinski Dr. Soukoulis
Name of Drug, Strength of Drug, Dosage (How do you take it), and Frequency 1 2 3
Prescription Drugs (Including ones prescribed by Blue Ridge Dermatology) Over-the Counter Products (Pain, antihistamines, lotions, laxatives, etc) Supplements (Herbal, vitamin/mineral, dietary)
PHARMACY:
LOCATION:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
*DRUG ALLERGIES: Drug:
NKDA - No Known Drug Allergies Reaction:
Drug:
Reaction:
Drug:
Reaction:
Drug:
Reaction:
*Indicate on Green MOA Sheet
Last Updated :
USE BACK FOR MORE SPACE
CURRENT MEDICATION LIST Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
Drug &
Frequency:
Dosage:
DRUG ALLERGIES: Drug:
Reaction:
Drug:
Reaction:
Drug:
Reaction:
Drug:
Reaction:
Drug:
Reaction:
Drug:
Reaction:
Last Updated :
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice is a summary only. You may request a detailed accounting of our privacy policy from our front desk personnel. *How we may use and disclose your health information. We use health information about you for treatment, payment and for administrative purposes, and to evaluate the quality of care that your receive. For example, your health information may be shared with other providers to whom you are referred. Information may be shared by paper, mail, electronic mail, fax, or other methods. We may use or disclose your health information without your authorization for the above reasons. Our office policy engages rules to detect, prevent and mitigate identity theft in connection with new and existing accounts. Beyond these situations, we will ask for your written authorization before using or disclosing your health information. If you sign an authorization to disclose information, you can later revoke it to stop any future uses or disclosures. *Your rights. You have the right to look at or get a copy of your health information that we use to make decisions about you. We ask for a preliminary request and legally we have 10 business days in which to respond. If you request copies, we may charge you a cost-based fee. You also have the right to request a list of certain types of disclosures of your information that we have made. If you believe your health information is incorrect, or information is missing, you have the right to request that we correct the existing information or add the missing information. The medical record of your care legally belongs to the Practice. *Our legal duty. We are required by law to protect the privacy of your health information, provide this notice about our privacy practices, follow the privacy practices that are described in this notice, and seek your acknowledgment of receipt of this notice. We may change our privacy policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more information about our privacy policies, contact the person listed below. *Privacy complaints. If you are concerned that we have violated your privacy rights, our privacy policies, or you disagree with a decision we made about access to your health information, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. If you have questions or complaints, please contact Tomita Lawrence, Practice Administrator, Blue Ridge Dermatology, 1151 Thirteenth Street, Waynesboro, Virginia 22980. (540) 949-6934.
ACKNOWLEDGMENT OF RECEIPT OF SUMMARY NOTICE OF PRIVACY PRACTICES: I, ____________________________, have received this summary notice of the Privacy Practices of Blue Ridge Dermatology.
__________________________________
____________________________
Signature of Patient/Authorized Representative (Or Parent/Legal Guardian of minor)
Date
_______________________________ Chart Number
*Given Entire Policy Notice
PLEASE COMPLETE BACK OF FORM
Disclosures to Family Members and Friends
Patient Name:__________________________________ I hereby give my permission to disclose personal information about my treatment to the following individuals: (Example: Spouse, parent/legal guardian, friend, etc.) Name:__________________________ Phone#: ___________________
Relationship:___________________
Name:__________________________ Phone#: __________________
Relationship:___________________
Name:__________________________ Phone#: __________________
Relationship:___________________
Name:__________________________ Phone#: __________________
Relationship:___________________
____ YES, I acknowledge that anyone not listed above will be unable to communicate with Blue Ridge Dermatology on my (or my child’s) behalf. May we leave personal medical information on your home answering machine or cell phone voicemail? ___ YES
______________________________________ Patient/Authorized Representative Signature (Or Parent/Legal Guardian of minor)
___NO
_______________________ Date
Annual Verification ______________________________________ Patient/Authorized Representative Signature (Or Parent/Legal Guardian of minor)
_______________________ Date
______________________________________ Patient/Authorized Representative Signature (Or Parent/Legal Guardian of minor)
_______________________ Date
______________________________________ Patient/Authorized Representative Signature (Or Parent/Legal Guardian of minor)
_______________________ Date
______________________________________ Patient/Authorized Representative Signature (Or Parent/Legal Guardian of minor)
_______________________ Date
______________________________________ Patient/Authorized Representative Signature (Or Parent/Legal Guardian of minor)
_______________________ Date
BLUE RIDGE DERMATOLOGY, P. C. CHARLES R. PAULY, M. D., P.C. CYNTHIA H. DENT, M. D. KEITH A. KNOELL, M. D. JANE M. LYNCH, M. D. PAUL A. KRUSINSKI, M. D. INES W. SOUKOULIS, M.D. DIPLOMATES AMERICAN BOARD OF DERMATOLOGY 1151 THIRTEENTH STREET WAYNESBORO, VIRGINIA 22980 TELEPHONE (540) 949-6934 FAX (540) 943-5540
130 WALKER STREET LEXINGTON, VIRGINIA 24450 TELEPHONE (540) 464-3509 FAX (540) 464-1799
CONSENT TO TREAT A MINOR Patient Name________________________________
M__F__
DOB___________
Street Address_________________________________________________________ Mailing Address________________________________________________________ Phone_____________________________________________ Parent/Guardian_____________________________________ The following statement was read by the parent/guardian listed above: I give written permission for Blue Ridge Dermatology, P.C. and its representative physicians to make medical decisions/treat my child as listed above, since I, the parent/legal guardian listed above may not be present at all of his/her scheduled visits. I understand that I or another parent/legal guardian must be present for my child’s first appointment. If I am unable to attend the first appointment, I, __________________________ , give permission to ___________________________ (Name of Parent/Guardian) (Name of adult to be accompanying child) to accompany my child and authorize treatment for my child in accordance with the office policy of Blue Ridge Dermatology. This includes bringing the child into the office of Blue Ridge Dermatology, providing a history of present illness, disclosing protected health information, accompanying consented research study procedures, and witnessing any physical exam completed by the provider. This adult has the responsibility to relay any diagnosis, treatment plan or prescription(s) to the parent or legal guardian mentioned above. I agree to be available by phone and to be financially responsible for all copays and coinsurance. I also understand this signed consent will be valid until the minor child is 18 years of age, or unless I withdraw this permission in writing. I certify that I understand and agree to the foregoing permission statement. Signature: ________________________ Date:______________________________ 09/17/2015
