PATIENT REGISTRATION FORM

Transcription

1 LASER SK IN CARE CE NTER DERMATOLOGY ASSOCIATES 3828 Schaufele Avenue, Suite 300 Long B each, Ca (562 ) PATIENT REGISTRATION FORM MRN ( ) New Patient ( ) Update PATIENT NAME: BILLING ADDRESS: RESPONSIBLE PARTY NAME: CITY, STATE, ZIP: PERMANENT ADDRESS: CITY, STATE, ZIP: HOME PHONE: ( ) CELL PHONE: ( ) SEX: Male Female BIRTHDATE: PT. SS# RESPONSIBLE PARTY SS# RELATIONSHIP TO PATIENT: Self Spouse Parent Other REFERRING DOCTOR NAME & ADDRESS: PRIMARY CARE DOCTOR NAME & ADDRESS: IS PATIENT: Single Married Other IS PATIENT: Employed Full-Time Student Part-Time Student Other OCCUPATION: EMPLOYER NAME: EMPLOYER ADRESS/PHONE: SPOUSE OR NEAREST RELATIVE NAME/PHONE/ADDRESS: INSURANCE INFORMATION: HMO: MemorialCare Foundation, Greater Newport Physicians, and Blue Shield Direct ONLY Medicare Patients: Have you recently joined a Medicare Advantage Plan? If yes, please identify PRIMARY INSURANCE: INSURANCE CO. NAME: INSURANCE CO. ADDRESS: POLICY HOLDER NAME: RELATIONSHIP TO PATIENT: EMPLOYER: SECONDARY INSURANCE: INSURANCE CO. NAME: INSURANCE CO. ADDRESS: POLICY HOLDER NAME: RELATIONSHIP TO PATIENT: EMPLOYER: I.D. #: GROUP#: I.D.#: GROUP#: POLICY HOLDER SEX: F or M BIRTHDATE: POLICY HOLDER SEX: F or M BIRTHDATE: COPAY: $ DEDUCT: $ VERIFIED: COPAY: $ DEDUCT: $ VERIFIED: To comply with the PHI (private healthcare information), do you authorize the office to call you at home and leave a message to assist the offic e in carrying out TPO (Treatment, Payment, and Operations), such as appointment reminders and insurance items? Yes No Patient or Guardian Signature AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize this physician/clinic to release to my Insurance Company any information required to receive payment in the course of my examination or treatment which could include HIV, communicable disease or drug abuse. AUTHORIZATION TO PAY: I hereby authorize payment directly to the business office of this physician/clinic for the surgical and/or medical benefits, if any, otherwise pay able to me for services. I understand that I am financially responsible for charges not covered by my insurance. Patient authorizes the Doctor to deposit checks receiv ed on Patient s account when made out to the Patient. I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf. A photocopy of this Assignment shall be considered as effective and valid as the original. SIGNED (Patient or Parent, if minor): DATE:

2 LASER SKIN CARE CENTER DERMATOLOGY ASSOCIATES 3828 Schaufele Avenue, Suite 300 Long Beach, Ca (562) MRN: Patient Name: Date of Birth: HISTORY & INTAKE FORM: PAST MEDICAL HISTORY: (check all that apply) Anxiety Depression Leukemia Arthritis Diabetes Lung Cancer Artificial joints End Stage Renal Disease Lymphoma Asthma GERD (Acid Reflux) Pacemaker Atrial fibrillation Hearing Loss Prostate Cancer BPH (Benign Prostatic Hyperplasia) Hepatitis Radiation Treatment Bone Marrow Transplantation Hypertension Seizures Breast Cancer HIV/ AIDS Stroke Colon Cancer Hypercholesterolemia Valve Replacement COPD (Emphysema) Hyperthyroidism None Coronary Artery Disease Hypothyroidism Other PAST SURGICAL HISTORY: (check all that apply) Appendix Removed Heart Transplant Melanoma Surgery Bladder Removed Hysterectomy: Fibroids Lumpectomy (Right, Left, Bilateral) Basal Cell Cancer Surgery Hysterectomy: Uterine Cancer Ovaries Removed: Endometriosis Biological Valve Replacement Joint Replacement, Knee ( Right, Left, Bilateral) Ovaries Removed: Cyst Breast Biopsy (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Ovaries Removed: Ovarian Cancer Breast Reduction Joint Replacement within last 2 years Prostate Removed: Prostate Cancer Breast Implants Kidney Biopsy Prostate Biopsy Colectomy: Colon Cancer Resection Kidney Removed (Right, Left ) PTCA Colectomy: Diverticulitis Kidney Stone Removal Skin Biopsy Colectomy: IBD Kidney Transplant Spleen Removed Coronary Artery Bypass Mastectomy (Right, Left, Bilateral) Squamous Cell Carcinoma Surgery Gallbladder Removed Mechanical Valve Replacement Testicles Removed (Right, Left, Bilateral None TURP Other SKIN DISEASE HISTORY: (check all that apply) Acne Eczema Poison Ivy Actinic Keratoses Flaking or Itchy Scalp Precancerous Moles Basal Cell Skin Cancer Hay Fever/ Allergies Psoriasis Blistering Sunburns Melanoma Squamous Cell Skin Cancer Dry Skin Other: Do you wear Sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes No Do you have family history of Melanoma? Yes No If yes, which relative(s)? Any other family history?

3 MEDICATIONS: (Please enter all current medications) ALLERGIES: (Please enter all allergies) Social History: (Please check one) CIGARETTE SMOKING: ALCOHOL USE: LANGUAGE: Never smoke Yes English Quit: former smoker No Spanish Smokes less than daily Other: RACE: White Black/ African American Asian American Indian or Native Alaskan Native Hawaiian/ Pacific Islander ETHNICITY: Hispanic/ Latino Non-Hispanic/ Latino Are you pregnant or breastfeeding? Yes No PHARMACY: Name: Street: City: Zip Code: How often do you exercise? Once a day A few times a week A few times a month Never What is your caffeine use? Once a day A few times a week A few times a month Never OCCUPATION: EMPLOYER'S NAME:

4 PATIENT RESPONSIBILITY FOR COPAYMENT, DEDUCTIBLE, LATE CANCELLATION AND NO SHOW FEE I agree to be financially responsible for all co payments and my deductible. I assume the responsibility of paying for all services rendered, and for payment of any services which are not covered by my insurance policies. Due to an increasing number of "no shows" and late cancellation we have found the need to implement this new cancellation policy: Patient should inform the office no later than twenty-four hours prior to scheduled appointments if they are unable to keep the appointment. If cancellation of an appointment occurs after the twenty-four hour time period, or if the patient "no shows" without warning, the patient will be charged a fee according to the length of time allotted for appointment. Regular office visits will be charged a $25 fee. Mole or Skin Cancer or Cysts or other procedure appointments will be charged a $75 fee. Moh's Micrographic Surgery (extended skin cancer surgery) will be charged $200 due to the cost of the lab technician, who is paid on a per case basis. Cosmetic procedure deposits of approximately $150 may also be forfeited if insufficient notice is given. The amount of cancellation fees for cosmetic procedures will be based on the particular procedure and the time and resources involved. Extenuating circumstances may be considered. If patient has any questions regarding these fees, please ask for further explanation BEFORE your next appointment or treatment. This policy allows the doctors to accommodate other patients who are able to take cancelled appointments. I understand and agree to all of the above terms and conditions. Patient Name: Patient Signature: Date:

5 STATEMENT OF PATIENTS RIGHTS AND RESPONSIBILITIES Laser Skin Care Center/ Dermatology Associates has adopted the following written policies concerning the rights and responsibilities of all patients. 1. Patients have the right to be treated with respect, consideration and dignity. 2. Patients have the right to know the name of the physician responsible for coordinating care. The patient also has the right to know the name of the person responsible for the procedures and or treatment provided. 3. Patients have the right to actively participate in the decision regarding medical care and to refuse treatment to the extent permitted by law. 4. Patient have the right to privacy concerning their own medical care and to expect that all communications and records pertaining to their care will be treated as confidential, except when required by law, patients are given the opportunity to approve or refuse their release. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. Staff not directly involved in the patient s care should have the permission of the patient to be present. 5. Patients are provided to the degree known, complete information concerning their diagnosis, evaluation, treatment and prognosis. 6. Patients have the right to examine and receive an explanation of their bill regardless of source of payment. They also have the right to know fees for specific services. 7. Patients have the right to know what Laser Skin Care Center/ Dermatology Associates rules and regulations apply to their conduct as a patient and to know provisions for after-hours and emergency care. 8. Patients have the right to be informed by the physician or a delegate of the physician of his/her continuing health care requirements following his/her discharge. 9. Patient rights apply also to the person who may have legal responsibility to make decision regarding medical care on behalf of the patient. 10. Patients have the right to know the services available at the organization. 11. Patients have the right to know the credentialing of health care professionals at Laser Skin Care Center/ Dermatology Associates. 12. Patients have the right to be informed that marketing and advertising regarding the competence and capabilities of the organization is no misleading. 13. Patients are informed about procedures for expressing suggestions to the organization and policies regarding Grievance procedures and external appeals, as required by State and Federal law and regulations. 14. A patient is expected to be considerate of other patients and staff, and to observe the no smoking policy of the office and to be respectful of the property of others and the office. 15. It is understood that a patient assumes the financial responsibility of paying for all services rendered whether through third party payers, or being personally responsible for payment for any services which are not covered by insurance policies. Signature: Date: APPROVED BY GOVERNING BODY 06/14/2010 BILL OF RIGHTS ( ) NEW POLICY/PROCEDURE (X) SEPERCEDES ATTACHED LASER SKIN CARE CENTER/ DERMATOLOGY ASSOCIATES 3828 Schaufele Avenue, Suite 300 Long Beach, Ca (562) Page 1 of 1

6 Do you have: Patient Screening for Aerosol Transmissible Diseases (ATD) A history of Tuberculosis: Yes No If yes, explain: Symptoms of tuberculosis: Productive cough (>3weeks): Yes No If yes, explain: Bloody sputum Yes No If yes, explain: Night sweats Yes No Fatigue Yes No Malaise Yes No Unexplained weight loss Yes No Flu & Other Aerosol transmissible diseases including pertussis, measles, mumps, rubella, chicken pox, meningitis: Do you have: How long? Explain: Fever? Yes No Body aches? Yes No Runny nose? Yes No Sore throat: Yes No Headache? Yes No Nausea? Yes No Vomiting or diarrhea? Yes No Fever and respiratory symptoms? Yes No Severe coughing spasms? Yes No Painful, swollen glands? Yes No Skin rash, blisters? Yes No Stiff neck, mental changes? Yes No In compliance with California OSHA Title 8, Section 5199, health care facilities must pre-screen patients for aerosol transmissible diseases. Procedures are not performed on patients suspected or identified as having aerosol transmissible diseases. Chronic Respiratory Diseases (NOT ATD's, and not considered infectious) do not disqualify a patient from treatment under California OSHA Title 8, Section 5199: he Do you have: Asthma? Yes No Chronic upper airway cough syndrome "postnasal drip? Yes Allergies? Yes No Gastroesophageal reflux disease (GERD)? Yes Emphysema? Yes No Chronic obstructive pulmonary disease (COPD)? Yes Bronchitis? Yes No Dry cough from ACE inhibitors? Yes

7 Laser Skin Care Center Dermatology Associates 3828 Schaufele Avenue, Suite 300 Long Beach, Ca Phone: 562/ FAX: 562/ Patient Name: Date: Please provide us with your address for appointment reminders, promotions, skin tips and advice. Please kindly write down the reason for your visit with us today. We will be happy to provide you information on any of the following skin concerns and areas of interest. (Please check all that apply) Other: Other:

8 Laser Skin Care Center Medical History Patient: Date: Account# Reason for today s visit: Are you allergic to any medications? YES NO If yes, list: Do you have now, or have you ever had diseases or conditions of: (Please check Yes or No) Lungs: Yes No Other Systemic: Yes No Bronchitis Diabetes Emphysema Thyroid Asthma Kidney Chronic Cough Stomach Morning Cough Bowel Hepatitis or yellow skin Glaucoma Arthritis/Joint Deformity Convulsions, Epilepsy Fainting Vascular: Yes No High Blood Pressure Chest Pain Heart Attack Heart Murmur Irregular Heart Beat Pacemaker Phlebitis List your current medications: Do you Drink Alcohol? YES NO If YES drinks per Day Do you use IV Drugs? YES NO If YES, what? How much? Have you had or have you been exposed to HIV (AIDS)? YES NO Have you ever had dental anesthesia (Novacaine)? YES NO Any bad reaction? YES NO Skin: When you are exposed to sun do you: Tan only Tan and burn Burn Have you ever had skin cancer? YES NO Does anyone in your family have a history of specific skin disease? YES NO If Yes, Who? Do you have a history of any specific skin diseases? YES NO If yes, please list: List any other disease or condition we should know about: List surgical procedures you have had in the last 6 months: Please answer the following questions: A.. Do you smoke? YES NO If yes, how much: B. Do you bleed easily? YES NO C. (Women) Are you pregnant YES NO Due Date: D. Do you have artificial Joint(s) YES NO Completed by: Patient Reviewed by Date

9 LASER SKIN CARE CENTER/ DERMATOLOGY ASSOCIATES Patient Consent Form We keep a record of the health care services we provide you. You may ask to see and copy that record. You mayask to correct that record. We will not disclose your record to others unless you direct us to do so. You may seeyour record or get more information about it by contacting this office and asking for the Privacy Officer. By my signature below I acknowledge receipt of the Notice of Privacy Practices. Signature of patient or legally authorized individual Print name if signed on behalf of the patient Relationship- parent, legal guardian Please initial and provide any additional information as required to enable us to appropriately use and disclose your protected health information for the following: I agree to be contacted for appointments or follow-up information regarding my care by: Phone Answering Machine Mailed Appointment card reminders THE NUMBERS TO USE INCLUDE: THE ADDRESS TO SEND MAILING IS: I agree to allow the practice to use and disclose information regarding my care as needed: (Choose one) Without restrictions/limits to family and friends Restricted/limited to the family and friends listed below PLEASE LIST THE INDIVIDUALS YOU WISH TO PARTICIPATE IN YOUR CARE: If you initialed WITHOUT RESTRICTIONS above, the individuals listed here will be considered the primary and/or emergency individuals you wish for us to communicate with regarding your care. If you initialed RESTRICTED above, the individuals listed here will considered the only individuals you wish for us to communicate with regarding your care. If these individuals are not available in an emergent situation we may need to use our discretion regarding use and disclosure of your medical information.

10 PLEASE LIST (IF ANY) INDIVIDUALS YOU DO NOT WISH TO PARTICIPATE IN YOUR CARE: This portion only needs to be completed if you initialed RESTRICTED above and wish to list individuals here. I agree to permit the practice to request and obtain or forward previous medical records if deemed necessary to provide me with proper care and treatments I agree to be contacted regarding treatment options and health-related benefits I agree to the release of all my insurance and medical information to other health care providers, my insurance company, Medicare or any third party payer to facilitate healthcare, processing of claims and audit payments I agree to to be financially responsible for any cosmetic and non-covered services I agree (if applicable) and give permission to have the following listed persons bring my Child into the practice for medical treatment AUTHORIZED INDIVIDUALS INCLUDE: MEDICARE RECIPIENTS ONLY- For Billing Medicare- I request that payment of authorized MEDICAREbenefits be made either to me or on my behalf to the practice for any services furnished to me by the providers. Iauthorize any holder, of my medical information, to release to the Center for Medicare and its agents anyinformation needed to determine these benefits or the benefits payable for related services. Medicare Patient Signature or legally authorized individual Date These consents will remain in effect until revoked by me in writing. Signature of patient or legally authorized individual Date