WILLIAM SAWCHUCK, M.D. GAYLE MASRI-FRIDLING, M.D OLD COURTHOUSE ROAD, SUITE 303 VIENNA, VA TELEPHONE: (703) FAX: (703)

Transcription

1 WILLIAM SAWCHUCK, M.D. GAYLE MASRI-FRIDLING, M.D OLD COURTHOUSE ROAD, SUITE 303 VIENNA, VA TELEPHONE: (703) FAX: (703) PATIENT INFORMATION Name: Date of Birth: Address One: Address Two: City: Social Security #: State: Zip: Sex: Home Phone #: Emergency Contact: Work Phone #: Emergency Phone #: Cell Phone #: Relationship to Emergency Conatct: GUARANTOR INFORMATION Name: Date of Birth: Address One: Address Two: City: State: Zip: Home Phone #: Social Security #: Work Phone #: Sex: Cell Phone #: INSURANCE INFORMATION Primary Insurance: Secondary Insurance: Certificate #: Certificate #: Group Number: Group Number: Group Name: Group Name: Co-Pay: Co-Pay: Subscriber Name: Subscriber Name: Subscriber Date of Birth: Subscriber Date of Birth: AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or to my provider when they accept assignment. I understand and agree that I am financially responsible for the charges not covered by my insurance company. (All self-pay accounts and co-pays are due at the time of the visit. There are no exceptions to his policy.) APPOINTMENT POLICY: If you do not notify us of your intent to cancel a scheduled appointment at least 48 hours prior, then you will be responsible for a fee of $75.00 for surgical appointments and $50.00 for all other appointment types. We also ask that if you are running late for your scheduled appointment that you notify us as early as possible. We realize that extenuating circumstances do occur and the final decision to assess for this fee is left to the discretion of the doctor. Signature (patient or parent if minor) Date

2 MEDICAL HISTORY AND INTAKE FORM Patient Name: Date: Date of Birth: Age: Preferred Pharmacy: Pharmacy Phone: Pharmacy Address: Primary Care Physician: Physician Phone: Primary Physician Address: Reason for Today s Visit: MEDICAL HISTORY (Please circle all that apply) Anorexia HIV/AIDS Anxiety Hypercholesterolemia Arthritis Hypertension Artificial joints Hyperthyroidism Asthma Hypothyroidism Atrial fibrillation Leukemia BPH (Benign Prostatic Hyperplasia Lung Cancer Bipolar Disorder Lupus Bone Marrow Transplantation Lymphoma Breast cancer Obsessive Compulsive Disorder Colon Cancer Organ Transplantation COPD (Emphysema) Pacemaker Coronary Artery Disease Panic Disorder Depression Prostate Cancer Diabetes Radiation Treatment End Stage Renal Disease Schizophrenia Environmental Allergies Seizures GERD (Acid Reflux) Stroke Hearing Loss Valve Replacement Hepatitis None Other DERMATOLOGIC HISTORY (Please circle all that apply) Accutane/Isotretinoin Use Eczema Acne Flaking or Itchy Scalp Actinic Keratosis Hay Fever Allergies Herpes (Type: ) Alopecia Melanoma Bacterial Infection (Type: ) Poison Ivy Basal Cell Carcinoma Skin Cancer Precancerous Moles Blistering Sunburns Psoriasis Contact Dermatitis Squamous Cell Carcinoma Skin Cancer Dry Skin None Other

3 PAST SURGICAL HISTORY (Please circle all that apply) Appendectomy Kidney Removed (Right, Left) Basal Cell Carcinoma Surgery Kidney Stone Removal Biological Valve Replacement Kidney Transplant Bladder Removed Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Mastectomy (Right, Left, Bilateral) Breast Implants Mechanical Valve Replacement Breast Reduction Melanoma Surgery Colectomy: Colon Cancer Resection Ovaries Removed: Cyst Colectomy: Diverticulitis Ovaries Removed: Endometriosis Colectomy: IBD Ovaries Removed: Ovarian Cancer Coronary Artery Bypass Prostate Biopsy Gallbladder Removed Prostate Removed: Prostate Cancer Heart Transplant PTCA Hysterectomy: Fibroids Skin Biopsy Hysterectomy: Uterine Cancer Spleen Removed Joint Replacement, Hip (Right, Left, Bilateral) Squamous Cell Carcinoma Surgery Joint Replacement, Knee (Right, Left, Bilateral) Testicles Removed (Right, Left, Bilateral) Joint Replacement within last 2 years TURP Kidney Biopsy None Other REVIEW OF SYSTEMS (Please circle all that apply) Have you experienced or are you currently experiencing any of the following? Changing mole Yes No Headaches Yes No Rash Yes No Cough Yes No Fever or chills Yes No Shortness of breath Yes No Problems with healing Yes No Wheezing Yes No Problems with scarring Yes No Defibrillator Yes No (hypertrophic or keloid) Immunosuppression Yes No Blood thinners Yes No Chest pain Yes No GI upset with antibiotics Yes No Night sweats Yes No Allergy to adhesive Yes No Unintentional weight loss Yes No Allergy to lidocaine Yes No Thyroid problems Yes No Allergy to topical antibiotic Yes No ointments Sore throat Yes No Artificial heart valve Yes No Blurry vision Yes No Artificial joint within the past 2 Yes No years Abdominal pain Yes No MRSA Yes No Hepatitis C Yes No Premedication prior to procedures Yes No Organ transplant Yes No Rapid heartbeat with epinephrine Yes No Joint aches Yes No Neck Stiffness Yes No Problems with bleeding Yes No Pregnancy or planning a pregnancy Yes No Muscle weakness Yes No Nursing Yes No

4 FAMILY HISTORY (Please circle all that apply) Mother: Living/Deceased Age: Cause of Death: Father: Living/Deceased Age: Cause of Death: Acne Mother Father Sister Brother Daughter Son Other None Arthritis Mother Father Sister Brother Daughter Son Other None Asthma Mother Father Sister Brother Daughter Son Other None Diabetes Mother Father Sister Brother Daughter Son Other None Eczema Mother Father Sister Brother Daughter Son Other None Hay fever Mother Father Sister Brother Daughter Son Other None Allergies Mother Father Sister Brother Daughter Son Other None Lupus Mother Father Sister Brother Daughter Son Other None Psoriasis Mother Father Sister Brother Daughter Son Other None Basal Cell Carcinoma Mother Father Sister Brother Daughter Son Other None Squamous Cell Carcinoma Mother Father Sister Brother Daughter Son Other None Melanoma Mother Father Sister Brother Daughter Son Other None Accutane/Isotretinoin Use Mother Father Sister Brother Daughter Son Other None Cancer & Type (Other than Skin Cancer): Mother Father Sister Brother Daughter Son Other None When you are exposed to the sun do you: SUN EXPOSURE (Please check or circle all that apply) Always burn Usually burn, tan minimally Sometimes mild burn, tan uniformly Rarely burn, always tan well Very rarely burn, tan very easily Never burn, tan very easily Where did you grow up? Did you have sunburns every summer in childhood? Yes No Have you had at least one blistering sunburn? Yes No If yes, how many? Ever use a tanning bed? Yes No If yes, how many times/how often? Do you wear sunscreen? Yes No If yes, what SPF? SOCIAL HISTORY (Please circle all that apply) Smoking: Current smoker? Yes No If yes, how much? Former smoker? Yes No If yes, how much? Never smoker? Yes No Alcohol Use: Do you drink alcohol? Yes No Frequency: Occupation: Hobbies: Any other information you would like us to know: Reviewed: Date: Update:

5 Patient Name: DOB: / / Encounter Date: / / Medication Record It is important to our physicians that each of our patients update medications at each visit in order to prevent drug interactions, ensure patient safety and deliver quality care. We kindly ask all patients to list all medications. Always include over-the-counter, herbals and vitamins/mineral/dietary supplements. Please also list your drug allergies on the line below. The clinical assistant will use the shaded area to review your medications with you for the next seven visits. Drug Allergies: Appointment Date: *Shaded Area for Office Use Only* Medications Dose Frequency Route Is the patient currently taking these medications? (Prescription, Over-the-Counters, Herbals, Vitamin/Mineral/Dietary Supplements) (Ex. 2x/Day) (Ex. Injection, By Mouth, Patch, etc.) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N)

6 NOTICE OF PRIVACY PRACTICES WILLIAM SAWCHUK, M.D. GAYLE MASRI-FRIDLING, M.D Old Courthouse Road, Suite 303 Vienna, VA Phone: (703) Fax: (703) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORAMTION. PLEASE REVIEW IT CAREFULLY. This notice takes effect on SEPTEMBER 23, 2013 and remains in effect until we replace it. The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We need to maintain a record of your services at our office in order to provide you with quality care and to comply with certain legal requirements. LAW REQUIRES US TO: 1. Keep your medical information private. 2. Give you this notice describing our legal duties, privacy policies, and your rights regarding your medical information. 3. Follow the terms of the current notice. WE HAVE THE RIGHT TO: 1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the top of this notice. FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you with your other health care providers to assist them in treating you. FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information. FOR DATA BREACH NOTIFICATION PURPOSES: We may use your medical information to provide legally required notices of authorized acquisition, access, or disclosure of your health information due to a breach. FOR HEALTHCARE OPERATIONS: We may use and disclose your medical information for our healthcare operations. This might include measuring and improving quality, evaluating the performance of employees conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you. HEALTH OVERSIGHT ACTIVITIES: We may disclose medical information to an agency providing health oversight for oversight activities authorized by law: including audits; civil, administrative, or criminal investigations; proceeding; inspections; licensure; disciplinary actions; or other authorized activities.

7 LAW ENFORCEMENT: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies. APPOINTMENT REMINDERS: We may use and disclose medical information for purposes of sending you appointment postcards or otherwise reminding you of your appointments. MEDICAL PHOTOGRAPHY: Due to the nature of dermatological practice we may require medical photographs to aid in your treatment. These photographs will be combined with your medical records and are subject to the same constraints as your other medical information. They will not be used of marketing, shared with the public, or disclosed to any third party not directly involved in the coordination of your medical care. WITH MY CONSENT William Sawchuk, M.D., and Gayle Masri-Fridling, M.D., may call my home or other designated location and leave a message on voic or in person in reference to any items that assist the practice in carrying out treatment, payment, and healthcare operations. This includes any call pertaining to my clinical care, including laboratory results, among others. WITH MY CONSENT William Sawchuk, M.D., and Gayle Masri-Fridling, M.D., may mail to my home or other designated locations any items that assist the practice in carrying out treatment, payment, or healthcare operations, as long as they are marked Personal and Confidential. These items include appointment reminder cards and patient statements. You have the right to request restrictions on how the practice uses and disclosure your medical information. The practice is not required to agree to your requested restrictions, but if it does, it is bound by this agreement. YOU HAVE A RIGHT TO 1. Look at or get copies of certain parts of your medical information. You may request that we provide copies in a format other than photocopies. You must make your request for medical records in writing. You may make a request by using the form our office provides to request access. You may also request access by sending a letter to our practice. If you request copies, we will charge you $0.50 for each page, as well as charge for the postage if you want the copies mailed to you. 2. Request that we communicate with you about your medical information by different means or to different locations. This request must be made writing. If you have questions about this notice or if you think that your privacy rights have been violated, please contact us.

8 WILLIAM SAWCHUCK, M.D. GAYLE MASRI-FRIDLING, M.D OLD COURTHOUSE ROAD, SUITE 303 VIENNA, VA TELEPHONE: (703) FAX: (703) PROTECTED PRIVACY AGREEMENT NAME F BIRTHDATE M 1. I wish to be contacted in the following manner (check all that apply): Home Telephone O.K. to leave message with detailed information Leave message with call-back number only Work Telephone O.K. to leave message with detailed information Leave message with call-back number only Written Communication O.K. to mail to my home address O.K. to mail to my work/office address below: O.K. to fax this to this number Other 2. Please list any designated relative or friend that you authorize our office to communicate with concerning your Protected Health Information (PHI). Be advised that it is your responsibility to keep the practice informed of any changes to this information. Name Address Telephone # Relationship I DO NOT WISH TO HAVE MY PHI DISCLOSED TO ANYONE OTHER THAN MYSELF 3. I have had the opportunity to read and review the NOTICE OF PRIVACY PRACTICES that was given to me. By signing this form, I am consenting to the use and disclosure of my personal health information by William Sawchuk, MD, and Gayle Masri-Fridling, MD, in order to carry out treatment, payment, and healthcare operations. I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. If I do not sign this consent, William Sawchuk, MD, and Gayle Masri-Fridling, MD, may decline to provide treatment to me. Signature of Patient/Legal Guardian Printed Name of Patient Date Patient s DOB Printed Name of Legal Guardian (if applicable)