EAST VALLEY DERMATOLOGY CENTER
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1 EAST VALLEY DERMATOLOGY CENTER Adult and Pediatric Dermatlgy VALLEY SKIN CANCER SURGERY PATIENT INFORMATION RECORD Please Use Black Ink Only Patient Infrmatin Patient s Name Last First Middle Initial Address Apt# City State Zip Date f Birth Age Scial Security # Primary Phne: ( ) O.K. t leave message with detailed infrmatin (Extended) Secndary Phne: ( ) O.K. t leave message with detailed infrmatin (Extended) Wrk Phne: ( ) O.K. t leave message with detailed infrmatin (Extended) Leave message with call-back number nly (Brief) Leave message with call-back number nly (Brief) Leave message with call-back number nly (Brief) Address Sex: Female Male (Fr access t ur Patient Prtal and t receive prmtinal infrmatin n prducts sld at EVDC) Emergency Cntact Phne # Relatinship t Patient: Marital Status: Single Married Widwed Divrced Separated Emplyer If Student: Full Time Part Time Primary Care Physician / Referring Dctr Phne # In rder fr ur healthcare practice t meet the qualificatin requirements under the American Recvery and Reinvestment Act f 2009, we are required t btain the fllwing infrmatin: 1. Ethnicity: Hispanic r Latin/a Nn-Hispanic D nt wish t respnd 2. Race: American Indian r Alaska Native Black r African American Asian White Other Race Native Hawaiian r Other Pacific Island Hispanic D nt wish t respnd 3. Language: English Other
2 Insurance Infrmatin Primary Insurance Relatinship t Patient: Self Spuse Parent Plicyhlder s Name Other Date f Birth Phne Scial Security# If different frm patient: Address Apt# City State Zip Emplyer Phne # Secndary Insurance Relatinship t Patient: Self Spuse Parent Plicyhlder s Name Other Date f Birth Phne Scial Security# If different frm patient: Address Apt# City State Zip Emplyer Phne # Respnsible Party (if patient is under 18 years f age) Name Last First Middle Initial Address Apt# City State Zip Primary Phne # Secndary Phne # Date f Birth Address Emplyer Phne # _ Understanding Health Insurance Benefits C-Pay: This is the amunt that yu will be expected t pay upn check-in fr each appintment. Specialist Cpayments may be higher than what yu wuld nrmally pay fr yur PCP visits. Please be prepared t pay by Visa, MasterCard, Discver, Cash r Check at the time f service. Deductible: This is an amunt designated by yur plan that yu will pay fr cvered services each calendar year befre yur insurance plan begins t pay benefits fr certain cvered services. If yu have a surgical deductible, then prcedures such as bipsies, freezings, wart treatments etc. may be applied twards yur surgical deductible. C-Insurance: This is the percentage f the visit r prcedure that yu will be respnsible fr. If yu have a deductible in additin t c-insurance, yur deductible must first be met befre yur insurance will begin t pay. Once yur insurance carrier has prcessed yur claim, yu will receive an invice fr any remaining patient respnsibility. If yu have any questins regarding yur benefits, we recmmend that yu cntact yur insurance carrier directly t receive yur specific cverage details.
3 Pwer f Attrney If, during my status as a patient at East Valley Dermatlgy & Valley Skin Cancer Surgery, I becme incapacitated, I have a Medical Pwer f Attrney t prvide fr my recrds: Yes N Pwer f Attrney Name: Phne #: Pharmacy Infrmatin Lcal Pharmacy Name: Crss Streets: City: Mail Order Pharmacy Name: AUTHORIZATION TO VIEW PRESCRIPTION HISTORY FROM EXTERNAL SOURCE I authrize East Valley Dermatlgy Center & Valley Skin Cancer Surgery t view any and all available Prescriptin Histry frm an External Surce. I am aware that East Valley Dermatlgy Center & Valley Skin Cancer Surgery uses a secure cnnectin t SureScripts t send and receive mst prescriptins in the ffice. (Signature f Patient r Respnsible Party) (Date) (Relatinship t Patient) Authrizatin t Release Infrmatin, Assignment f Benefits and Ntice f Privacy Practices: I authrize the release f any/all infrmatin regarding my diagnsis and treatment t the fllwing persn(s) belw, until I ntify yu therwise: Name(s): By signing belw, I authrize payments f medical benefits t the prvider fr services rendered r t be rendered in the future, withut btaining my signature n each claim submitted. My signature will bind me as thugh I persnally signed the claim. I als authrize the release f any medical infrmatin necessary. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES. I als understand that if my accunt becmes delinquent and is referred t an utside cllectin agency, I may be cntacted by the fllwing methds including but nt limited t pre-recrded/artificial vice messages and/r use f an autmatic dialing device t the telephne numbers assciated with my accunt. We prhibit audi r vide recrding if the intent is t share it n a public website. Als, if yu are recrding fr yur wn persnal use, we prefer yu ask ur cnsent. I acknwledge that I have received The Ntice f Privacy Practices. Dermatlgy des NOT fall under Preventive/Well Visit cverage. Patients will be respnsible fr C-Pay/Deductible/C-Insurance. Must be 18 years r lder t sign this authrizatin: Patient s Name (print) Respnsible Party Signature Date **N changes t this plicy by the patient / respnsible party will be acknwledged. Questins may be directed t ffice persnnel.** 1100 S. Dbsn Rd., Suite 223 Chandler, AZ website: East Valley Dermatlgy ~ Valley Skin Cancer Surgery ~
4 East Valley Dermatlgy/Valley Skin Cancer Surgery Patient Name: Date f Birth: Date: Scial Histry Smking Status? 0 Current Smker 0 Frmer Smker 0 Nn Smker Have yu had a drink cntaining alchl in the past 12 weeks? 0 yes 0 n If yes select frequency belw: drinks r 0 7 r mre Have yu used recreatinal drugs in the past 12 mnths? 0 yes 0 n D yu use sun prtectin? 0 always 0 almst always 0 smetimes 0 hardly never 0 never Wmen nly: Are yu pregnant? 0 yes 0 n Wmen nly: If nt, are yu planning a pregnancy? 0 yes 0 n Wmen nly: Are yu currently breastfeeding? 0 yes 0 n SKIN TYPE 0 Always burns, never tans, extremely sun sensitive 0 Burns easily, then tans a little, very sun sensitive 0 Smetimes burns, then tans slwly, sun sensitive 0 Burns a little, always tans 0 Rarely burns, tans easily 0 Never burns, deeply clred Family Histry 0 Unknwn, Adpted Mther 0 Nne 0 Heart Prblems 0 Cancer 0 Eczema 0 Skin Cancer, Basal Cell 0 Skin Cancer, Squamus Cell 0 Skin Cancer, Type Unknwn 0 Melanma 0 Psriasis Father 0 Nne 0 Heart Prblems 0 Cancer 0 Eczema 0 Skin Cancer, Basal Cell 0 Skin Cancer, Squamus Cell 0 Skin Cancer, Type Unknwn 0 Melanma 0 Psriasis Siblings 0 Nne 0 Heart Prblems 0 Cancer 0 Eczema 0 Skin Cancer, Basal Cell 0 Skin Cancer, Squamus Cell 0 Skin Cancer, Type Unknwn 0 Melanma 0 Psriasis Children 0 Nne 0 Heart Prblems 0 Cancer 0 Eczema 0 Skin Cancer, Basal Cell 0 Skin Cancer, Squamus Cell 0 Skin Cancer, Type Unknwn 0 Melanma 0 Psriasis
5 Patient Name: Date f Birth: Date: Past Medical Histry N Histry f Skin Cancer Histry f Skin Cancer, Basal Cell Histry f Skin Cancer, Squamus Cell Histry f Skin Cancer, Unknwn Type Melanma Chrnic Acne Eczema / Dermatitis Psriasis Histry f specific skin disease Prblems with healing Develp kelids (scars) after surgery Latex Skin allergies Tape Skin allergies Hepatitis A Hepatitis B Hepatitis C Breast Cancer Cervical Cancer Prstate Cancer Cln Cancer Lung Cancer Thyrid Cancer Leukemia / Lymphma Cld sres / Herpes Shingles Hay Fever Hives Fd Allergies HIV / AIDS Page 2 f 2 TB (Tuberculsis) MRSA (Staph) Pacemaker Implantable Defibrillatr High Bld Pressure Strke Heart Attack Phlebitis r Bld Clt Diabetes Lung Disease Thyrid Disease Kidney r Bladder Disease Gastrintestinal Disease Liver Disease Clitis Gluten Sensitivity Yeast Infectin (antibitics) Arthritis Artificial Jints Seizures Lupus r cnnective tissue disease Anemia Bld transfusin Immune suppressin Organ transplant Anxiety Depressin
6 EAST VALLEY DERMATOLOGY CENTER Adult and Pediatric Dermatlgy VALLEY SKIN CANCER SURGERY Dermatlgic and Mhs Micrgraphic Surgery Medicatin List and Medicatin Allergies Date: Patient Name: Date f Birth: Medicatins: Please list any current medicatins that yu are taking, including ver the cunter. Name f Medicatin Strength Dse Allergies t Medicatins: Please list any medicatin allergies that yu are aware f. Name f Medicatin Reactin Prvider Reviewed: MA Entered:
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
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MEDICAL /HISTORY REGISTRATION FORM **PLEASE PRINT** Insurance Information (If this is cosmetic, please disregard this section)
Date: Sex M F **PLEASE PRINT** Insurance Infrmatin (If this is csmetic, please disregard this sectin) Patient Name: Address: City: State: Zip: SS#: Hme Ph: Cell: Are yu emplyed? Self Emplyed Retired Name
PATIENT INFORMATION. Last Name: First Name: Address: City/State/Zip: Phone: (H): (W): (C): Date of Birth: Gender: Male Female
PATIENT INFORMATION Date Last Name: First Name: Address: City/State/Zip: Phne: (H): (W): (C): Email: Date f Birth: Gender: Male Female EMERGENCY CONTACT INFORMATION Last Name First Name Middle Initial
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s
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