PATIENT INFORMATION AND ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT 1. Patient’s Name __________________________________________________________________________ Last

First

MI

______________________________________________________________________________________________________ Address

Street & Apt #

City

State

Zip

______________________________________________________________________________________________________ Home Phone

Cell Phone

Any restrictions for contacting you?

No

Other Phone

Yes Contact Restrictions:____________________________________________

E-mail address __________________________________________________ Age ______ Birthdate _____/______/______ Marital Status:

Married

Single

SS# _______-_______-________

Pt.’s Gender:

Female

Male

Spouses’ Name:___________________________________________________

Primary Care Physicians name & phone: _________________________________________________________________ Other referral source: ____________________________________________________________________________________ 2. Patient’s or Parent’s Employer___________________________________ Occupation______________________ Work Phone_______________________________ Ext:_________

Is it okay to call you at work?

Yes

No

Work Address___________________________________________________________________________________________ Street & Suite #

City

State

Zip

3. Emergency Contact ___________________________________________________________ Relationship to Patient________________________ ____________________________ Home Phone

_____________________________________ Work Phone

______________________________ Other Phone

______________________________________________________________________________________________________ Address

Street & Apt #

City

State

Zip

4. Name of Pharmacy: _____________________________________________________________________ Address: ____________________________________________________________ Street

City

State

Zip

Telephone _______________________

5. Current Medications: _____________________________________________________________________ _______________________________________________________________________________________ 6. Allergies: ____________________________________________________________________________________________ _______________________________________________________________________________________

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7. Primary Health Insurance Company_________________________________________________________ ____________________________________ ______________________________ ________________________________ Subscriber/ Member ID #

Group/ Account ID #

Ins. Phone

8. Primary Policy Holder’s Name: _______________________________________________ DOB _____/______/______

Address: ______________________________________________________Telephone _____________________ Street

City

State

Zip

Social Security #_________ -______ -_________Policy Holder’s Relationship to Patient: __________________________

9. Secondary Health Insurance Company_________________________________________________________________ ___________________________________ _______________________________ ________________________________ Subscriber/ Member ID #

Group / Account ID #

Insurance Phone

Secondary Policy Holder’s Name: ___________________________________________ DOB ______/______/________

Address: _________________________________________________________ Telephone __________________ Street

City

State

Zip

Social Security #_______ -______ -_________ Policy Holder’s Relationship to Patient: ___________________________

10. AUTHORIZATION FOR INSURANCE TO PAY I hereby authorize payment of medical benefits billed to my insurance company to be paid directly to Skin Specialists PA, the office of Tanya Reddick Rodgers, MD, FAAD. I hereby agree to promptly pay for any service(s) provided to me not covered by my insurance policy. I agree to pay all co-payments, deductibles, coinsurance, and for cosmetic services and/or products sold through Skin Specialists PA. If/when any of the above information changes, I will provide the updated information promptly. I also understand that I may change my emergency contact information at any time, by asking for and completing a new emergency contact form.

X

_____________________________________________________________________ Signature of Patient (if over 18) or parent/legal guardian

__________________________ Date

11. PATIENT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I understand that as part of the provision of healthcare services, Skin Specialists PA, the offices of Tanya Reddick Rodgers, MD, FAAD, creates and maintains health records describing my health information. This includes, but is not limited to, my health history, symptoms, diagnoses, examinations, test results, treatment and any plans for treatment. I have read and been provided with a copy of the Notice of Privacy Practices which provides a complete description of the uses and disclosures of certain healthcare information. By signing below, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment, and healthcare operations. I have the right to revoke this consent in writing except where disclosures have already been made in reliance on my prior consent.

X

____________________________________________________________________ Signature of Patient (if over 18) or parent/legal guardian

___________________________ Date

If signed by parent/legal guardian, please print name_________________________________________________________

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FINANCIAL AND OFFICE POLICIES We would like to welcome you to our office and are happy that you have chosen us for your dermatology needs. Our goal is to provide the best possible medical care for you and your family. In order to meet this goal, we need your assistance and understanding of our Financial and Office policies. Our Financial Policy is a necessary part of assuring the financial resources needed to maintain this healthcare facility for our patients. Office Visits - Private Pay Patients Full payment of services is due at the time of your visit. We accept cash, checks, Visa, MasterCard, Discover, and debit cards. Cosmetic Procedure & Products As we are all aware, cosmetic procedures and skin care products are not covered benefits under medical insurance. Therefore, payment is due at time of service or product purchase. We accept cash, checks, Visa, MasterCard, Discover, and debit cards. Insurance Companies We cannot guarantee how your insurance company processes and pays your claims. Your insurance is a contract between you and your insurance company. We are unable to provide you with exact costs of professional procedures performed by our providers due to the fact that insurance companies deduct contractual adjustments (contract between the insurance company and Skin Specialists PA), prior to applying any co-payments, coinsurances and or deductibles. Although we are participants in your plan, you will be responsible for all charges the insurance company deems patient responsibility.

Office - Visits Insured Most health plans require you to make a co-payment with each visit. Co-payment amounts cannot be billed and will be collected at the time of your visit. We accept cash, checks, Visa, MasterCard, Discover, and debit cards. In order to be consistent with insurance regulations, you are required to pay your co-payment before your office visit and deductibles are due at checkout, after services rendered. We accept checks, cash, credit and debit card payments. Non-Covered Services It is important to understand that some of the services provided to you may not be covered under your current insurance plan. Therefore, it is important that you check with your insurance company to verify your benefits. You will be responsible for full payment of any services not covered by your insurance at the time of your visit. Surgery Some minor surgical procedures are performed in our office. Most insurance carriers put these in the category of “surgery”, meaning that the procedure may be applied to a surgical deductible or coinsurance. Therefore, you may be billed for an amount over and above the usual visit co-payment. This may also mean that the procedure will need to be pre-certified. If the procedure is not covered by your insurance we will require 100% payment at the time of the surgery.

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Laboratory Services When you have a skin biopsy or culture done, we will send the specimen to an outside lab. Please note that we DO BILL your insurance for specimen collection, BUT the laboratory will bill your insurance/you separately for processing and diagnosis of the specimen. Appointments It is our goal to provide services to you in the most comfortable and timely manner possible. In order to achieve this, we ask that you be on time for your appointments. We realize your time is valuable and we endeavor to keep on schedule, while providing each patient with personalized care. However, emergencies do occur, and may cause delays in our schedule. We will try to keep you informed of these delays should they arise. Cancellation/No Show Fees: There is a $50 non-refundable fee ($100 for surgery) for each no show occurrence or untimely cancellation (untimely cancellation - any cancellation that is not provided 24 hours before scheduled appointment.) Patient Services We are happy to offer the following services to our patients for a nominal fee: Medical Record Copies up to 20 pages $15; Over 20 pages $25. Completion of Disability, Insurance, FMLA, Medical LOA, Social Security forms or dictated letters may incur a $25 fee. Please allow at least 48 hours for completion. Prescription Refills Prescription refill or change requests will be handled within 24 hours of the receipt of the request during regular office hours. Please contact your pharmacy so that a written request can be faxed to our office. No prescription refill or change requests will be handled after regular office hours or on the weekend. Children Of course we all love to see children; however, we ask that you monitor them at all times while you are in our office. If you are uncomfortable having them with you in the exam rooms, please make other arrangements for their care during your office visit. Notification of Changes In order for us to maintain accurate financial records, we ask that you notify us in writing of any changes regarding your insurance information and/or personal information, i.e., address, name changes, phone numbers and all other relevant information that may affect your financial status.

Thank you for choosing us for your dermatology needs. If you have any questions regarding these policies, please notify a member of our business office during regular hours. We will do our best to ensure your understanding of our policies so that we may concentrate on you and your care. I acknowledge that I have read and understand the contents of the financial and office policies for Skin Specialists PA.

X

Signature______________________________________________ Date______________________

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AUTHORIZATION TO COMMUNICATE HEALTH INFORMATION Who to Contact: I hereby authorize and give permission to Skin Specialists PA, the offices of Tanya Reddick Rodgers, MD, FAAD, to disclose and discuss any information related to my medical condition(s) to/with the following persons: _____________________________________ _______________________________________ Name

Relationship

_____________________________________ _______________________________________ Name

Relationship

CONTACT ME ONLY I Wish To Be Contacted In The Following Manner: Home Phone:

Cellular Phone:

Check All That Apply _ Ok to leave message with detailed information

_ Leave message with call-back number only

Work Phone: _ Ok to leave message with detailed information

_ Leave message with call-back number only

Written Communication: _ Ok to mail to my home address _ Ok to mail to my work/office address _ Ok to fax to this number___________________ The duration of this authorization is indefinite unless I revoke it in writing. I understand that requests for medical information from persons not listed above will require a specific authorization prior to the disclosure of any medical information.

X

Patient or Parent’s Signature ________________________________________ Date ______________ Office Staff Only Below Line

Signature of Witness______________________________________________ Date _______________

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PATIENT HISTORY FORM Name: _______________________________ Race: Marital Status: Number of children: How did you hear about our office? Height: Weight: Do you drink alcohol?

o o o o

Socially

Yes

Rarely Daily Socially

Never Have you ever had skin cancer?

o o

Yes (if so, what type?)

No Has anyone in your immediate family ever had skin cancer?

o o

Yes (if so, what type?)

No Do you have any skin diseases? Ex: eczema, psoriasis, rosacea etc.

Have you ever been exposed to HIV/Aids?

o o

Yes (please list)

No (Women) Are you currently pregnant and/or breastfeeding?

o o

Yes

No Please list surgeries that you have had in the past.

Daily

No Do you use any tobacco products?

o o o o

o o

Rarely

Never Do you use any illegal drugs?

o o

Date: __________________ Are you allergic to any medications?

Yes

Do you Keloid (type of scar)?

o o

Yes

No Do you have any electronic cardiac (heart) devices? (Pacemaker, Defibrillator)

o o

Yes

No Do you have any anxiety, depression, or are you Bi-Polar?

o o

Yes

No Do you have a thyroid condition or diabetes?

o o

Yes

No Please list any family history of any cancers in your immediate family.

o o o Do you have any health problems you take medication for? If so, what are the health conditions? Ex: high blood pressure, cholesterol etc.

No Do you have any artificial joints?

o o

Yes (if so, where?)

What are your chief complaints for your visit today?

No Do you require antibiotics before a surgical/dental procedure?

o o

Yes

No Do you bleed easily?

o o

**Please list any prescription, birth control, and over the counter medications that you are currently taking or take as needed.**

Yes No

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Cosmetic Interests Skin Specialists of Allen/Addison wants to provide you with complete dermatologic care. We offer an array of Cosmetic Services to serve a variety of needs. In order to serve you better, please place a check next to the Cosmetic Service Issue(s) that you would like to discuss with the doctor.

o o o o o o o o o o o o o o X

Body Contouring Unwanted Hair Facial Veins Facial Redness Wrinkle Fine Lines / Enlarged Pores Facial Scarring / Acne Scarring Parentheses-like creases around the mouth Under-eye Circles Sagging Facial and Neck Skin Leg Veins (Varicose Veins) Short Eyelashes Torn Earlobes Ear Piercing I have no cosmetic concerns that I’d like to discuss today

_________________________________________________________ PRINT - Patient Name

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_____________________ Date

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FINANCIAL POLICY Amendment (Effective 03/01/2013) Scheduling Deposits and Fees: Deposits will be applied to charges for services rendered. Charges for Reschedules, Cancellations, and No-Shows will be dealt with accordingly (see table below). See definitions below unless otherwise defined: 

No-Show: No notification and reschedule for scheduled appointment, OR call to cancel or reschedule appointment within 24 hours of appointment.



Cancellation: Call must be at least 24 hours of appointment on a working day.



Reschedule: Call to reschedule an appointment. Call must be at least 24 hours of appointment on a working day.



Working Day: Regularly scheduled office days. Weekends and office holidays are not considered working days. ITEM

DEPOSIT

RESCHEDULE

CANCELLATION

NO-SHOW

Standard office visit

$0

OK

OK

Billed a $50 fee

Surgery

$0

OK

OK

Billed a $100 fee

CoolSculpting

$250 up to 2 hour slot (additional for each 2hr slot)

 OK - Reschedule 3 working days earlier

$100 charge per 2 hour slot for cancellations within 3 working days

Charged deposit amount

$250

OK

OK

Charged deposit amount

Fraxel / Sculptra

 $100 charge per 2 hour slot for reschedules within 3 working days

Cosmetic Evaluations: 

CoolSculpting = $0 evaluation fee



Other items = to be booked as a standard appointment. If evaluation results in a non-medical evaluation then a $150 evaluation fee will be billed. Note that the $150 fee will be applied to the deposit/cost of any subsequently scheduled cosmetic procedure.

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ADDITIONAL DISCLOSURES

TO PATIENTS RECEIVING TREATMENT FOR WARTS, ACTINIC KERATOSIS, BIOPSIES OR ANY OTHER PROCEDURE THAT MAY TAKE MULTIPLE VISITS…. •

THERE MAY BE SEVERAL TREATMENTS REQUIRED FOR FULL RESOLUTION OF YOUR ISSUE.

•

YOUR INSURANCE MAY CONSIDER THESE TO BE “SURGICAL” PROCEDURES AND APPLY THE CHARGES TO YOUR DEDUCTIBLE.

•

PLEASE BE AWARE THAT EACH TREATMENT AND OFFICE VISIT SUBMITTED TO YOUR INSURANCE COMPANY MAY APPLY TO YOUR DEDUCTIBLE.

•

IF YOU ARE CONCERNED ABOUT THE COST OF THE BILL, PLEASE NOTIFY THE NURSE AND OUR BILLING STAFF CAN PROVIDE YOU WITH A COST ESTIMATE.

•

WE ARE BOUND BY OUR CONTRACTS WITH YOUR INSURANCE COMPANY AND ONLY CHARGE YOU FOR THE AMOUNTS WE ARE INSTRUCTED AS ALLOWED BY YOUR INSURANCE COMPANY.

•

IF YOU HAVE QUESTIONS, PLEASE FEEL FREE TO CONTACT OUR OFFICE AT 972-649-6644.

X Patient Signature: ____________________________________________________Date

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