INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
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- June Perry
- 6 years ago
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1 The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service. A clear understanding of our office policy is important to our professional relationship. INSURANCE AND MANAGED CARE We participate in most insurance plans. Please inquire upon check-in to see if we accept your plan to avoid billing problems later. If your insurance plan requires a referral, you must have a valid referral on file from your primary care physician. If your visit has not been authorized, you have the option of signing a waiver making you financially responsible for that visit or rescheduling your appointment until such time as your visit is authorized. APPOINTMENT CANCELING POLICY We kindly ask for 24 hours notice if you cannot keep your scheduled appointment so that we may fill that opening. We reserve the right to charge a $25.00 Missed Appointment fee if you do not cancel within that time frame. Please initial. COSMETIC REMOVAL OF BENIGN LESIONS A benign lesion is a spot or growth which in the physician s opinion is not cancerous or pre-cancerous and for which there is no medical reason to treat. Insurance companies will pay for the evaluation of these lesions, but will not pay for their removal. Lesions which may fall into this category include: certain moles, brown spots (so called liver or age spots), angiomas (blood vessel moles and broken blood vessels), seborrheic keratoses (warty moles), skin tags (small flaps of skin found around eyelids, neck, under arms, under breasts, and in groin), and milia (persistent whiteheads) on face and eyelids. If you have a benign growth which you would like to have removed, you must sign a waiver of liability agreeing to be personally and financially responsible and payment is expected at the time of treatment. If you have any questions, please feel free to inquire before signing below. I have read and understand the above policies. Patient signature Date Guarantor signature (if guarantor is not the patient) Date
2 Patient Authorization for Treatment, Payment & Photographs Name: ALL PATIENTS: I hereby authorize medical/surgical treatment, care and/or services by New England Dermatology & Laser Center and authorize payment directly to New England Dermatology & Laser Center for all medical/surgical benefits, if any, that may be payable to me under the terms of my health insurance policy. I fully understand that I am primarily and financially responsible for fees incurred and that payment to New England Dermatology & Laser Center is not contingent on any settlement, judgment, or verdict by which I eventually recover medical fees. I hereby consent to and authorize New England Dermatology & Laser Center to use and disclose any of my health information, including my medical records and prescription medical history, for purposes concerning my treatment, payment for health care provided to me or the health care operations of New England Dermatology & Laser Center or other treating health care provider or plan. Signature of patient or guardian Date PHOTOGRAPHS: I give New England Dermatology & Laser Center permission to take clinical photographs for my medical record. I understand that the photographs remain the property of the office and may be used anonymously for the purpose of furthering medical education. Signature of patient or guardian: Acknowledgement of Receipt of Notice of Privacy Practices It is the policy of New England Dermatology & Laser Center to provide all patients, or their parents, guardians or personal representatives, a copy of our current Notice of Privacy Practices prior to the date of the first service delivery, or upon the first visit to New England Dermatology & Laser Center after April 14, 2003, if feasible. This signed acknowledgement is to be filed in the medical record. I have received New England Dermatology & Laser Center's Notice of Privacy Practices Signature of patient or guardian Date Authorization to Disclose Protected Health Information to family, friends, and/or others By signing below, I have authorized New England Dermatology & Laser Center to disclose my Personal Health Information to the following family or others: Please complete YOUR personal contact information below: Home Phone: May we leave a message on your answering machine? Work Phone: May we leave a message on your answering machine? Cell Phone: May we leave a message or auto message on your VM? May we a message to you? You are required to state how long this consent is valid for: one year two years three years You may revoke this authorization at any time by stating in writing to our Privacy Officer. Patient or guardian signature: Date:
3 Initial HX Updated HX REVIEW OF SYSTEMS Who is your Primary Care Physician? Have you ever been a patient in our office? Yes No If yes, how long ago? What WAS the reason? What IS the reason for your visit today? Are you ALLERGIC or have you had ADVERSE REACTIONS to any MEDICATIONS, FOODS, LATEX OR RUBBER, or other products? Yes No If yes, please list and explain. List ALL MEDICATIONS, PRESCRIPTIONS, and/or NON-PRESCRIPTION drugs (including herbal medications, aspirin, birth control pills, hormones, allergy shots, vitamin, laxatives, pills for headache, arthritis, nerves, sleeping, pain, etc.) that you take daily. No Medications Please CIRCLE any of the following MEDICAL PROBLEMS you have or have had. List any others. HEART: High blood pressure, angina, heart attack, heart murmur, irregular heartbeat, pacemaker, artificial heart valve LUNG: Bronchitis, emphysema STOMACH, BOWEL or LIVER: Ulcers, colitis, diverticulitis, irritable bowel KIDNEY DISEASE: GYNECOLOGICAL: Irregular menstrual cycles METABOLIC: Diabetes, thyroid NEUROLOGIC: Migraine headaches, convulsions, stroke MENTAL HEALTH COUNSELING: Was medication prescribed? Yes No BLOOD: Bleeding, anemia ARTHRITIS: Rheumatoid, osteoarthritis, psoriatic, lupus BONE/JOINT IMPLANTS: Artificial knee, hip, metal pins, etc. VASCULAR: Varicose veins or blood clots in legs EYES: Glasses, contact lenses, glaucoma, cataracts, lens implants EARS: Hearing aid ALLERGIES: Asthma, hay fever, sinus, hives INFECTIOUS DISEASES: Hepatitis, Tuberculosis, HIV, other CANCER: Type: Treatment: Radiation Chemotherapy Year of Treatment: List Surgery & Year of Treatment: OTHER DISEASES:
4 Initial HX Updated HX Are you pregnant or could you be pregnant? Yes No After injury or surgery, have your scars healed satisfactorily? Yes No Have you or any family members had bleeding problems with dental procedures or surgery? Yes No Have you ever had a reaction to locally injected anesthesia (Novocaine/Xylocaine) similar to that which you may receive at the dentist? If yes, please explain: Yes No Have you had skin reactions to band aids, adhesive tape, antibiotic ointments or topical creams? Yes No Have you ever fainted? If yes, what were the circumstances? Yes No Prior to dental procedures or surgery, have you been advised to take antibiotics because of a heart problem, artificial joint implant or other reason? Yes No Please circle skin type: I Always burn, never tan II Always burn, but sometimes tan III Sometimes burn, but sometimes tan IV Never burn, always tan Please CHECK any skin problems you HAVE or have HAD: Eczema Psoriasis Cold sores Frost bite Warts Growth removed Skin cancer/melanoma Other: Have your brothers, sisters, parents, or children had any of the following? Please CHECK: Asthma, hay fever, sinus problems, hives Frostbite Eczema Warts Psoriasis Skin cancer/melanoma Severe acne Other: Do you smoke? Yes No Do you drink alcohol? Yes No Occupation: PATIENT SIGNATURE: For office use: Reviewed with the patient. By and/or
5 New England Dermatology & Laser Center MACRA Patient Registration Form In compliance with the HITECH Act to attain MACRA, we are required to obtain certain demographic & health information. This is an important part of your medical history and required for our clinical quality improvement measures. Please complete the information below. Patient: No Vaccinations & Health Information: Have you received a Flu Vaccination in the last year? Yes No Have you received a Pneumonia Vaccination in the last year? Yes No Height ft. in. Weight lbs. Tobacco Use: Never smoker Former smoker Current every day smoker Current some days smoker Heavy smoker Light smoker If smoking; number of packs per day: Date started smoking: Date stopped smoking: I allow New England Dermatology & Laser Center to access my prescription medication history from healthcare providers or pharmacies for treatment purposes. I will not allow New England Dermatology to access my prescription medication history allowing them to prescribe appropriately. Patient or guardian signature: Date:
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
Past Skin History (Please check the applicable boxes to the patient s history or choose the first box)
Patient: First M.I. Last Date of Birth: Address: City: State: Zip Code: Responsible Billing Party: Social Security #: DOB: Home Work: Mobile: Best Contact number for confirmation calls is: Email (Required):
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )
NAME (Please Print) First Name M.I. Last Name DATE of BIRTH / / - YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) Exam Date:,20 PRESCRIPTIONS DRUGS Please Print MEDICATIONS NAMES ONLY NO PRESCRIPTION
Patricia C. McCormack, M.D., F.A.A.D.
Patricia C. McCormack, M.D., F.A.A.D. Diplomate of the American Board of Dermatology Adult & Pediatric Dermatology www.patriciamccormackmd.com PATIENT INFORMATION Today s date: Last name: First name: of
New Patient Paperwork
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ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
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WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:
TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
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PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
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PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
PATIENT REGISTRATION FORM
Please Print PATIENT REGISTRATION FORM Date: Who can we thank for referring you to our office? Patient Name (First) (Middle) (Last) Preferred Name (if applicable) DOB Sex: Male Female Patients Address
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:
Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite
MedDerm Associates, Inc.
*Last Name: PATIENT INFORMATION Please write CLEARLY and include any apt. # s, etc.., * Required information Today s Date: *First Name: *Primary phone: *Sex: M F Marital Status: S M W D DP *SS#: *Race
FRAME CHIROPRACTIC South Price Road, Suite D-110 Tempe, Arizona Phone: Fax:
3330 South Price Road, Suite D-110 Tempe, Arizona 85282 Phone: 480.345.2080 Fax: 480.345.2199 W E L C O M E ABOUT YOU (please print) Today s Date: Patient Name: DOB: Age: SS#: Mailing Address: City: State:
CompassionMassage.com. Client Intake Form
Name: Phone: ( CompassionMassage.com Client Intake Form ) E-Mail: Address: _ City: State: Zip: Date of Birth: Occupation: Referred by: In case of emergency: Phone: ( Chiropractor: ) General & Medical Information:
STEPHEN C. SNITZER, D.D.S.,
STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE 14377 WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI 63017 (314) 434-2101 NAME How would you prefer to be addressed?
PATIENT HEALTH HISTORY
PATIENT HEALTH HISTORY Patient Name Today s Date Birthdate DENTAL HISTORY Reason for Today s Visit Are you having dental pain now? Former Dentist Date of last dental visit Last x-rays Check (!) if you
Twohig Dentistry Dental and Oral Health Information
Twohig Dentistry Dental and Oral Health Information Patient s name: Date: Please describe any specific dental problem or discomfort you are having at this time: How long has it been present? If you have
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Rise Chiropractic 239 S. French Broad Ave Asheville, NC
Rise Chiropractic 239 S. French Broad Ave Asheville, NC 28801 828.989.8369 1 Name: of Birth: Age: Sex: M F Address: City/State: Zip: Phone: (H) (W) (C) SS# Email: Occupation: Employer: Marital Status:
MEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
A B O U T Y O U D E N T A L I N F O R M A T I O N
1 A B O U T Y O U Full Name: Welcome to Voller Dentistry. We d like to get to know you better so that we can do our best to ensure your total oral health! Marital Status: Spouse s Name: Spouse s Occupation:
F M S M W D. Age Birth Date Gender Marital Status Cell Phone
MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
New Patient Paperwork
New Patient Paperwork Date: Phone: Patient: Last Name First Name Initial Street Address: City/State/Zip Code: Sex: M F Age: Birthdate: Single Married Widowed Separated Divorced Email: Newsletter? Y N Insured
Naturopathic & Acupuncture Intake Form (Age 14+)
Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair, B.Sc., ND 86 Norfolk St., Guelph 519-827-0040 Contact Information Naturopathic & Acupuncture Intake Form (Age 14+) Name: Gender: Age: Birth Date (dd/mm/yy):
New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
PATIENT DEMOGRAPHIC INFORMATION
PATIENT DEMOGRAPHIC INFORMATION Patient Name: (First, MI, Last) Sex: [ ] M [ ] F Birth Date: Age: SS#: Email: Race: Ethnicity: Language: Mailing Address: Work Ph: ( ) City: State: Zip Code: Home Ph: (
Patient Registration
Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married