Chesterfield Valley Dermatology Helen Kim-James, MD 100 Chesterfield Business Parkway, Suite 110 Chesterfield, Mo 63005 P: 636.532.0990 f: 636.532.0993 CHESTERFIELD VALLE DERMATOLOG PATIET IFORMATIO FORM PERSOAL IFORMATIO AME: Last: First: Ml: Age: SS: Sex: M / F Mailing Address (city, state, zip): Primary umber: Work umber: Email: Secondary umber: Employer: Marital Status: M / S / D / W Pharmacy (Location & Phone umber): EMERGEC COTAC ame: ame: Relationship: Relationship: Phone: Phone: REFERRAL IFORMATIO How Did ou Hear About Us? MD/lnsurance/ Friend/ Publication/ Other Referring Doctor: Primary Care Doctor: RESPOSIBLE PART (if different from patient) AME: Last: First: Ml: Address: Primary umber: Secondary umber: ISURACE COVERAGE - PRIMAR Company: SS: Subscriber (insured): Relationship: Self/ Spouse/ Child/ Other Address (if different from patient): ISURACE COVERAGE - SECODAR Company: SS: Subscriber (insured): Relationship: Self/ Spouse/ Child/ Other Address (if different from patient):
Chesterfield Valley Dermatology Medical History Patient ame: Age: Date: How were you referred to our office? Are you allergic to any medications? If yes, what? Please list the medications you are taking (prescription and over-the-counter): Have you ever had a reaction to anesthesia (numbing medication)? Do ever had: Arthritis Artificial Joint or Valve Asthma Autoimmune Disease (Lupus, MS, other) Blood Clots Cancer (Other than Skin Cancer) Chest Pain Chronic Cough Diabetes Epilepsy/Seizures Fainting Fever Blisters/Cold Sores Heart Attack Heart Murmur Hepatitis B or C High Blood Pressure HIV/AIDS Exposure Irregular Heart Beats Kidney Problems Mitral Valve Prolapse ausea or Diarrhea on Antibiotics Pacemaker Require Antibiotics for Dentist Shortness of Breath Sinusitis Thyroid Problems Tuberculosis east Infection from Antibiotics List any other diseases or conditions: List any surgeries: Do you know, or have you ever had: Skin Cancer (melanoma, basal cell carcinoma, or squamous cell carcinoma) "Pre" cancer Family History of Melanoma Problems healing Specific skin disease (eczema, psoriasis, rosacea, or other) Large scars or keloids Difficulty in slopping bleeding Skin rashes to foods Do you drink alcohol? If yes, how many drinks per day? Current or history of IV/illicit drug use? Do you smoke? If so, how much? (Women) Are you pregnant? Are you planning pregnancy soon? What is your occupation?
CVD POLIC IFORMATIO Insurance/Payment: Current insurance card(s) and copayment are expected at time of service. If you do not have your insurance card(s) at time of visit you will be considered a self pay patient. If your insurance requires a referral, it is your responsibility to acquire the referral before appointment date. If referral is not received before appointment date and you still want to be seen that day you will be considered a self pay patient. ou are responsible for any charges incurred if you provide incorrect information or if you do not update any insurance changes at each visit. Each patient's visit is accurately coded and documented to the best of our ability. Preventive care visits do not apply to dermatologic services and are not used by our office. Once the insurance company has paid its portion of the office charges, please be aware that you will receive a statement for any charges that you are responsible for (ie: copayment, coinsurance, deductible). Please understand that payment for these charges are due at the time the statement is received and that you will be charged a $10 late fee every month for any charges that are not paid before the next billing statement. Patients that have received two statements in the mail must pay balance prior to further services. Chesterfield Valley Dermatology does not offer payment plans (as of 2014). There will be a $30 service fee on all returned checks. Cancellation/Late Arrival: We value your time and make every effort to stay on schedule. If you are running late to your appointment, please call the office to notify us so we can accommodate or reschedule the appointment in consideration for other patient's appointment times. Please allow 24 hour prior notice should you need to cancel or reschedule an appointment. Failure to notify the office and not appearing for your office visit will result in a o Show charge of $30 and we reserve the right to charge $75 for a missed surgery/procedure. Minors: For your child's safety, a parent must accompany children for their initial visit. For additional visits a written consent to be seen without a parent is permitted. In Case of Divorce: The parent who brings the child is stating they have "joint legal custody" or "sole legal custody" and can make health care decisions for the child. The parent who brings the child is considered the Guarantor. They have accepted responsibility for the child and their charges. The statements will be sent to the Guarantor. It is expected that in the case of divorce the two parties will handle payment arrangements without the involvement of the office. Billing for Delinquent Accounts: If your account becomes delinquent (not paid after second billing statement), it will be referred to a collection agency. Accounts placed in collection will be assessed a 40% collections fee by the agency in addition to any attorney fees or court costs that may incurred in an attempt to collect the debt. I, (please print name/relationship) / / SELF, am the responsible party for (patient) and take full responsibility of any services not covered by the insurance company for any office visit with Dr. Helen Kim-James. I (initial) have filled all the information to the best of my knowledge and agree with the above policies for Chesterfield Valley Dermatology (CVD). Patient or Responsible Party Signature: X DATE: RECEIPT OF OTICE OF PRIVAC PRACTICES: My signature below indicates that I have received and/or reviewed a copy of my physician's otice of Uses and Disclosures of Protected Medical Information (otice of Privacy Practices). Patient or Responsible Party Signature: X DATE: [Copies of otice of Privacy Policies are available upon request]
Chesterfield Valley Dermatology Helen Kim-James, MD EVALUATIO OF SKI LESIO(S) It is important that you read this information carefully and completely. ITRODUCTIO Skin cancer detection, treatment, and prevention are team efforts that involve the combined efforts of you and your doctors. The best way to prevent skin cancer is to wear appropriate skin cover and sunscreen, particularly in the summer months. Indoor tanning facilities should be avoided. If there is a lesion or growth that you or one of your other doctors has a concern about, please point it out to Dr Kim-James. In addition, if you have a mole which has grown or changed in color, it should be pointed out as well. Any growth on the skin that itches or has been bleeding should be examined. our dermatologist may give you an opinion about a skin lesion but without a biopsy it is only an estimate. It is important to note that no physician can ever be absolutely sure that any skin lesion is noncancerous without removing it. Although uncommon, even a skin biopsy can be inaccurate at times. Skin cancer screening is a tool that a dermatologist may recommend to help detect skin cancer on your body. Lesions that are unusual or appear to be cancerous will be pointed out, and may be biopsied. Whenever a lesion is biopsied, it is sent to a pathologist to be examined. Lesions which appear to be benign (non-cancerous) will not all be pointed out to you by your dermatologist. The frequency of your recommended skin cancer screenings is determined by your personal and family history. In order to have a skin cancer screening, it is important that you disrobe and wear a gown. Skin cancer screening appointments must be made in advance so that the proper amount of time is available. WHAT!S A BIOPS? When a lesion is biopsied, it is only sampled so that a diagnosis can be made. This means that if the growth is diagnosed as a skin cancer, more work will need to be done to ensure that it has been properly treated. This may involve a second surgery either by your dermatologist, a Mohs surgeon (a subspecialty of dermatology), or a plastic surgeon. The decision is based on what type of cancer you have and where it is located on your body. In some cases, the cancer may also be treated with a chemotherapy cream or radiation. WHAT IS LIQUID ITROGE? Liquid nitrogen is a very cold liquid which dermatologists use to treat pre-cancerous lesions. The nitrogen will destroy the pre-cancerous cells and prevent them from turning into a skin cancer. When this technique is used, the treated area is expected to blister, then scab, then heal. The healing process generally takes a week, but can take as long as 2-3 weeks. If a lesion is treated with liquid nitrogen and it does not fully heal, or if it comes back, it is important that you let your doctor know. HEALTH ISURACE Most health insurance plans cover both skin cancer screening and treatment. DISCLAIMER Informed-consent documents are used to communicate information. This informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all inclusive in defining other methods Initials 1 Rev. 9/2012
of care and risks encountered. our physician may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge. Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing the consent below. COSET FOR EVALUATIO OF A SKI LESIO 1. I hereby authorize Helen Kim-James, MD to evaluate my skin lesion(s). 2. I have received the following information sheet: EVALUATIO OF SKI LESIO(S) 3. 1 understand that if I do not disrobe, a complete skin cancer screening cannot be performed if I am scheduled for one. Patient or Person Authorized To Sign for Patient. Date Initials 2 Rev. 9/2012