Cape Cod Dermatology, LLC 134 Ansel Hallet Rd West Yarmouth, MA 02673 508-771-9779 Fax-508-771-4355 www.capecodderm.org

William Fiske, M.D.

Sasha Girouard, M.D.

Rosemara Hughart, M.D.

PLEASE fill out and bring the enclosed Forms to your appointment. We will also need to scan your insurance cards. If your insurance is an HMO and requires a referral, it is your responsibility to notify your Primary Care Physician of your appointment date and have the referral sent to us. Please arrive 10 minutes prior to your scheduled appointment. This is to ensure that your paperwork is in order. We are tightly scheduled and may need to re-schedule your appointment if you are late. There is a fee for missed appointments. Please note that patients under the age of eighteen must be accompanied by a parent or legal guardian.

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DIRECTIONS FROM HYANNIS: Rte 28 or Rte 132 around Airport Rotary continuing On Rte 28 to Yarmouth- at set of lights at Railroad Tracks, take LEFT onto Yarmouth Rd. This road is also Willow St. -Go straight for a Mile and a half passed N-STAR Electric on Your right. Take next RIGHT at set of Lights onto HIGGINS CROWELL Rd then 1ST LEFT onto ANSEL HALLET RD. We are 2nd Building on Left #134 directly across from UPS Bldg. DIRECTIONS FROM RTE 6: EXIT 7 – Take LEFT off exit onto WILLOW St. About ¼ mile down, take your LEFT at the Traffic Lights onto HIGGINS CROWELL RD. Then take 1st LEFT onto ANSEL HALLET Rd. We are the Second building on the LEFT - #134 Ansel Hallet Rd. The UPS building is directly across the street from us.

CAPE COD DERMATOLOGY, LLC PATIENT INFORMATION Last Name:____________________________________First:__________________________Middle:__________________ Sex:_________ Date of Birth:_____________________________ SS#___________________________________ Mailing Address:_____________________________________________________________________ City__________________________________________________State:_______________________Zip________________________ Street Address (if Different)________________________________________________________________________________ Home Phone:_______________________________________Cell Ph#_____________________________________________ Work#__________________________________________Emergency#_____________________________________________ Email address:_______________________________________________________ Employer:________________________________________________ Occupation:___________________________________ Responsible Party (if not self):__________________________________________________ Primary Care DR:________________________________________________ Spouse’s Name:_____________________________________________Spouse’s Date of Birth:______________________

INSURANCE INFORMATION Primary Insurance:_____________________________________________________ID#_________________________________ Subscriber:___________________________________________________Date of Birth:______________________ Secondary Insurance:_____________________________________________________ID#_________________________________ Subscriber:____________________________________________________________________________ I AUTHORIZE THE RELEASE TO MY INSURANCE CARRIER(S) OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM(S) AND AUTHORIZE PAYMENT OF BENEFITS TO DR. WILLIAM FISKE, DR. SASHA GIROUARD, AND/OR DR. ROSEMARA HUGHART FOR SERVICES RENDERED. I UNDERSTAND AND AGREE THAT (REGARDLESS OF MY INSURANCE STATUS) I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE OF MY ACCOUNT FOR ANY SERVICES RENDERED. A PHOTOCOPY OF THIS FORM MAY BE USED IN LIEU OF ORIGINAL.

SIGNATURE:___________________________________________________________DATE:___________________

Please note: The below information is REQUIRED by the government to prove that we have achieved “meaningful use” of our Electronic Health Record System. Race (please circle one): Caucasian (White)

Black or African American

Asian

Native American

American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

Prefer Not to Say

Other:__________________________________

Ethnicity (please circle one): Latino/Hispanic

Not Latino/Hispanic

Other

Preferred Language (please circle one or write in response): English

Other:____________________________________________

Place of Birth:___________________________________________________

Prefer Not to Say

History and Intake Form Past Medical History: (please circle all that apply) Anxiety Coronary Artery Disease Arthritis Depression Asthma Diabetes Atrial fibrillation End Stage Renal Disease Bone Marrow Transplantation GERD BPH Hearing Loss Breast Cancer Hepatitis Colon Cancer High Blood pressure COPD HIV/AIDS High Cholesterol NONE

Thyroid Problems Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke

Other:_______________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Past Surgical History (please include dates): _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Skin Disease History: (please circle all that apply) Acne Dry Skin Actinic Keratoses (pre-cancers) Eczema Asthma Flaking or Itchy Scalp Basal Cell Skin Cancer Hay Fever/Allergies Blistering Sunburns Melanoma

Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer

NONE Other __________________________________________________________________________________ If positive personal history of melanoma, please indicate date of diagnosis and treatment course:_______________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Do you have a family history of Melanoma? Yes No If yes, which relative(s)? _________________________________________________________________________________ Do you have a family history of squamous cell carcinoma or basal cell carcinoma? Yes No If yes, which relative(s)? _________________________________________________________________________________

Medications: (Please enter all current prescription medications as well as, over-the-counter, vitamins, herbs, supplements) Name of Medication Dose Frequency Route (oral, IV, etc.)

Allergies: (Please enter all allergies including drug, food, substance allergies, i.e. Latex) Allergic to: Describe reaction

Social History: (Please circle all that apply) Cigarette Smoking: Currently Smokes Has smoked in the past Never smoked Former Smoker (If so, indicate quit date:_________) Do you wear sunscreen?

No

Alcohol Use: EtOH- None EtOH- less than 1 drink per day EtOH -1-2 drinks per day EtOH -3 or more drinks per day

Yes

If yes, indicate SPF here:_______ Family Dermatology History: (That you feel we should be aware of) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Preferred Pharmacy Name: _______________________________ Pharmacy phone#: _______________________________ Pharmacy address:_______________________________

What is your main reason for today’s visit: _____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Review of Systems: Are you currently or recently experiencing any of the following? Check yes or no Symptom Yes No New or changing moles New skin growths Recent hives Rash Malaise Fever or chills Night sweats Recent episodes of joint aches or swelling Myalgias (muscle aches or pain) Sore throat Cough Unintentional weight loss Problems with healing Muscle weakness Shortness of breath Problems with bleeding Problems with scarring (keloids, etc) Immunosuppression Hay fever Chest pain Thyroid problems Blurry vision Abdominal pain Bloody stool Bloody urine Neck stiffness Headaches Seizures Wheezing Anxiety Depression Other Symptoms: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ALERTS: (please circle all that apply) Allergy to Adhesive Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement Blood thinners Defibrillator MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heart beat with epinephrine Are you pregnant or currently trying to get pregnant?

CAPE COD DERMATOLOGY, LLC 134 ANSEL-HALLET RD WEST YARMOUTH, MA 02673 508-771-9779

If desired, please list below a Relative or Friend that you would give permission to inform or discuss your Medical Information, Biopsy results, or Plan of Care: NAME

RELATIONSHIP

PHONE #

Please check below if you agree to give our office permission to leave messages on your answering machine for: X Confirming Appointments ___ Detailed Messages with Medical Information (such as lab results, prescription information, medical advice, and/or biopsy results) Signature _____________________________________________________________Date________________________

Please sign below if you DO NOT Wish to have our office leave messages. Signature _____________________________________________________________Date________________________

Please read the following information carefully… BILLING POLICIES: 1) All insurance cards must be presented at every visit. All insurance co-payments are expected at the time of service. Billing for insurance co-payments may incur a $5 fee. 2) The way your name appears on your insurance card must be reflected in all paperwork filled out for Cape Cod Dermatology, LLC so that we can accurately bill your insurance company. 3) If required by your insurance company: All insurance referrals are the responsibility of the patient. Failure to get an insurance referral will result in the patient being billed for the services rendered by Cape Cod Dermatology, LLC. 4) All self pay charges are expected to be paid at the time of service, unless prior arrangements have been made with the billing office. 5) Cape Cod Dermatology, LLC will make every reasonable attempt to bill each patient’s insurance company. However, if the insurance company rejects the claim the responsibility becomes that of the patient. 6) Kindly give 24 hours for cancelled appointments. Cape Cod Dermatology, LLC charges a $75 fee for missed appointments. Each patient is allowed to miss one appointment after which the fee will be charged for all subsequent missed appointment. Repeated missed appointments may result in dismissal from the practice.

INDEPENDENT CONTRATORS: I understand that Dr. Rosemara Hughart and Dr. Sasha Girouard are directly employed by Cape Cod Healthcare and practice at Cape Cod Dermatology, LLC’s premise solely as independent contractors.

Print Name:_________________________________________ Signature:_____________________________________________

Date:____________________________

Patient Portal Access Agreement - OPTIONAL Cape Cod Dermatology, LLC provides access to a patient portal as a courtesy in partnership with Modernizing Medicine for the exclusive use of its established patients. All users must be established by a previous office visit. We strive to keep all of the information in your records correct and complete. If you identify any discrepancy on your record, you agree to notify us immediately at 508-771-9779. Additionally, by using the patient portal, the user agrees to provide factual and correct information. The user also agrees to the following: 1. Do not use portal communication if there is an emergency. Dial 911 or go to the Emergency Room. 2. No Internet based triage and treatment is provided via the patient portal. Diagnosis can only be made and treatment rendered after the patient schedules and sees a provider. 3. We will usually respond to non-urgent emails within 48 hours. Do NOT use the patient portal for urgent problems – please call the office. If you have no received an email from us within 3 working days, please CALL the office. After you agree to the Policy and Procedures and sign the Consent Form, we will attempt to send a “welcome message” email to you. This will provide a link to the Portal login screen. *If you have not received an email from us within 3 working days, please CALL the office. Cape Cod Dermatology, LLC offers secure viewing and communication as a service to our patients who wish to view parts of their records and communicate with our staff. While we believe that the IT infrastructure and data are safe and secure, it does not guarantee unforeseen adverse events cannot occur. Secure messaging can be a valuable communications tool, but has certain risks as does all evolving technology. In order to manage these risks we need to impose some conditions of participation that you agree to by signing this consent form. We require the correct email address and you MUST inform us if it ever changes. If you think someone has learned your password, you should promptly go to the Patient Portal and change it. If you forgot your password please use the “forgot password” option on the portal or call our office. Cape Cod Dermatology, LLC is not responsible for a breach of private medical information if: the patient using the portal is using a computer workstation or device that could be compromised , if the patient discloses his/her portal password, or if said breach occurs due to any other outside factors beyond Cape Cod Dermatology, LLC’s reasonable control. I acknowledge that I have read and fully understand this consent form. I understand the risks associated with online communications between my physician and patient. I acknowledge that using the patient portal is entirely voluntary and will not impact the quality of care I receive from Cape Cod Dermatology, LLC should I decide against using the patient portal. It is my responsibility to notify Cape Cod Dermatology, LLC if there is a change in my email account or I feel that my secure password has been breached. I agree not to hold Cape Cod Dermatology, LLC or any of its staff liable for network infractions beyond its reasonable control. Signature__________________________________________________________ Date________________ Please print all information clearly: Full Name _______________________________________________________ Date of Birth_____________________

Email Address _______________________________________________________________________________

NOTICE OF PRIVACY PRACTICES Cape Cod Dermatology, LLC strives to give you the highest quality health care and to have a relationship with you that is built on trust. This trust includes our commitment to respect the privacy and confidentiality of your protected personal health care information. Cape Cod Dermatology, LLC is required to maintain the privacy of your personal health information. This includes health information about you that is collected during the course of your treatment that may be kept in either paper or electronic form. Information such as your symptoms, test results, diagnoses, treatment, care plan, demography and payment information are examples of your health information that may be collected and stored in your health record. Information about your care that we have received from other providers may also be included in your health record. Cape Cod Dermatology, LLC retains the right to use and share your protected health information for the following purposes:  Treatment, to help coordinate and manage care with your providers (physicians, hospitals and other caregivers). For example, Cape Cod Dermatology, LLC may discuss your treatment plan with your physician or surgeon.  Payment, Cape Cod Dermatology, LLC will use and share your personal health information as necessary to bill and collect payment for the health care services provided to you. For example, if you have health insurance, your health care provider will share your medical information with your insurance company (for example, Blue Cross Blue Shield or Medicare). Cape Cod Dermatology, LLC has indirect treatment relationships with your providers (such as laboratories & pharmacies) and may have to disclose your personal health information for the purposes of treatment, payment, or health care operations.  Cape Cod Dermatology, LLC may use and share your personal health information with its business associates for activities that are known as health care operations. For example, Cape Cod Dermatology, LLC will share your information with Cape Cod Healthcare as required for auditing purposes. For example, Cape Cod Dermatology, LLC may utilize off site data backup and shredding companies. Business associates of Cape Cod Dermatology, LLC are required to protect your personal health information.  As required by state and federal laws and regulations and for required public health reporting.  As authorized by and as necessary to comply with workers compensation laws.  Cape Cod Dermatology, LLC may use your health information to obtain your telephone number and/or address to contact you about scheduled or cancelled appointments, registration/insurance updates, billing or payment matters, surgical appointments, test results, and/or other matters related to your care as a patient. You have the right to request in writing for restrictions on the use of your contact information (for example, you may request that voicemail and/or other messages not be left at your contact number). Your additional rights regarding your protected health information:  Under ordinary circumstances, uses and disclosures not described in this Notice of Privacy Practices require your authorization.  You have the right to restrict disclosures of your personal health information to your health plan when you pay out of pocket in full for your health care visit. Please note that a request for information restriction must be accompanied by a written request at the time of your office visit in addition to payment in full for said visit.  Cape Cod Dermatology, LLC will notify you in the event of a breach of unsecured personal health information.  You have the right to a copy of your medical record. Requests for medical records must be made in writing. Cape Cod Dermatology, LLC will respond to your request within 14 business days.  If you are asked to and give written permission for the use and/or disclosure of your health information, you may withdraw such consent at any time in writing except to the extent that Cape Cod Dermatology, LLC has already acted upon your previously provided consent.  Cape Cod Dermatology, LLC retains the right to change its privacy practices and the terms of this notice at any time. Cape Cod Dermatology, LLC retains the right to make the new notice provisions effective for all protected health information it retains. You may request a copy of the current notice at any time by contacting the office. Signature:_________________________________________________ Date:_______________________________ Print Name:_________________________________________________