NORTH DALLAS DERMATOLOGY ASSOCIATES
NAME:
□
Male DOB:
/ /
Age:
Last
First
Race:
□ Caucasian
□ American Indian or Alaska Native
□ Asian
□ African American
□ Native Hawaiian or Other Pacific Islander
□ Other
Ethnicity:
□ Hispanic or Latino
□ Not Hispanic or Latino
Your visit today may include labs, cultures and/or skin biopsies. We generally receive results of lab work/cultures in approximately
3-5 days and skin biopsy results in 7-10 days. We will call you with results and any additional information prescribed by your
physician. For BENIGN / NEGATIVE results on any tests listed above:
YES, you may leave a detailed message informing me of my results at the following telephone #:_________________________
NO, do not leave a detailed message. Please leave call back information only on my voicemail.
Who is your Primary Care Physician? NAME:______________________________ Phone #:__________________________________
Did a physician refer you to our clinic?
□ Yes □ No
If a physician did not refer you, how did you find our clinic?
PHARMACY NAME
PHONE
ADDRESS
CHIEF COMPLAINT
(Reason for your visit)PLEASE CHECK ANY CONDITIONS THAT CURRENTLY APPLY TO YOU: OR
□
None Apply To Me
□ Anxiety
□ Colon Cancer
□ Hepatitis, Type: __________ □ Lymphoma
□ Arthritis
□ COPD
□ Hypertension
(high blood pressure)□ Prostate Cancer
□ Asthma
□ Coronary Artery Disease
□ HIV/AIDS
□ Seizures
□ Atrial Fibrillation
□ Depression
□ Hypercholesterolemia
□ Stroke
□ Bone Marrow Transplant
□ Diabetes
□ Hyperthyroidism
□ OTHER _____________
□ BPH
(benign enlargement of the prostate)□ End Stage Renal Disease
□ Hypothyroidism
□ Breast Cancer
□ GERD
□ Leukemia
□ Bleeding Tendency
□ Hearing Loss
□ Lung Cancer
PAST MEDICAL HISTORY: (past illnesses/surgeries)
□ Appendix (Appendectomy)
□ Heart : Coronary Artery Bypass Surgery
□ Ovaries (Oophorectomy) : Endometriosis
□ Bladder (Cystectomy)
□ Heart : PTCA
□ Ovaries (Oophorectomy) : Cysts
□ Breast : Mastectomy
□ Heart : Mechanical Valve Replacement
□ Ovaries (Oophorectomy) : Cancer
□ Right □ Left □ Both
□ Heart : Biological Valve Replacement
□ Prostate(Prostatectomy) : Prostate Cancer
□ Breast: Lumpectomy
□ Heart : Transplant
□ Prostate(Prostatectomy) : Prostate Biopsy
□ Right □ Left □ Both
□ Joint Replacement - Knee
□ Prostate (Prostatectomy) : TURP
□ Breast Biopsy
□ Right □ Left □ Both
□ Skin : Skin Biopsy
□ Breast Reduction
□ Joint Replacement - Hip
□ Skin : Basal Cell Carcinoma
□ Breast Implants
□ Right □ Left □ Both
□ Skin : Squamous Cell Carcinoma
□ Colon Cancer Resection
□ Kidney : Biopsy
□ Skin : Melanoma
□ Colon : Diverticulitis
□ Kidney : Nephrectomy
□ Spleen (Splenectomy)
□ Colon : Inflammatory Bowel Disease
□ Kidney : Kidney Stone Removal
□ Testicles (Orchiectomy)
□ Gallbladder (Cholecystectomy)
□ Kidney: Transplant
□ Uterus (Hysterectomy) : Fibroids
□ Uterus (Hysterectomy) : Uterine Cancer
□ OTHER __________________________________________
OVER
EMA INTAKE FORM PAGE 1
□
Female
If yes, Dr.
DEMOGRAPHIC INFORMATION
MEDICAL INFORMATION
PAGE 2
□
Acne
□ Dry Skin
□ Hay fever/Allergies
□ Psoriasis
□ Actinic Keratosis
□ Eczema
□ Poison Ivy
□ Blistering Sunburns
□ Flaking or Itchy Scalp
□ Precancerous Moles
Personal History of Skin Cancer
Family History of Skin Cancer
□
Basal Cell Carcinoma
Do you wear sunscreen daily?
□
Yes
□
No
□
Basal Cell Carcinoma
□
Squamous Cell Carcinoma
If yes, what SPF?
□
Squamous Cell Carcinoma
□
Melanoma
Do you tan in a tanning salon?
□
Yes
□
No
□
Melanoma
□
Unsure
Multiple blistering sunburns as a child?□
Yes
□
No
□
Skin Cancer, unsure which type
□
No History of Skin Cancer
History of atypical moles?
□
Yes
□
No
□
No Family History of Skin CancerLIST ALL CURRENT MEDICATIONS
LIST ALL ALLERGIES TO PRESCRIPTION AND NON-PRESCIPTION MEDICINES
□
Never Drink Alcohol
□
less than 1 drink per day
□ 1-2 drinks per day
□ 3+ drinks per day
□
Never Smoked
□
Quit, Former Smoker
□
Smokes Less Than Daily
□
Smokes Daily
SOCIAL HISTORY
Personal History of Sun Exposure
SKIN DISEASE HISTORY
SKIN HISTORY
MEDICATION HISTORY
PATIENT REGISTRATION
Date:_________________________ Patient Name:_____________________________________________ Date of Birth:_______________ Marital Status:_____________
First Last
Address:__________________________________________ City:_____________________ State:_________ Zip:_______________ Street/Apt #/PO Box
*Preferred Phone#: Home( ) Cell( ) Work( ) Is it OK to leave a detailed message? ____Yes ____No
Home #:_____________________________ Cell #:______________________________ Work #:____________________________ Email:____________________________ Sex: F M SSN:__________________ Preferred Language:________________________ Race: ____White ____Black/African American ____Asian ____American Indian ____Hawaiian/Pacific Islander ____Other Ethnicity: ____Hispanic ____Non-Hispanic/Non-Latino ____Other/Non-determined
Referred by: *Physician( ) *Patient to Patient( ) *Family( ) Insurance( ) Internet( ) Other( )____________________________ *Please give Name/Address:____________________________________________________________________________________ Employer:______________________________________________________ Occupation:___________________________________ Preferred Pharmacy:_________________________________________ Pharmacy Phone:___________________________________ Pharmacy Address: :_________________________________________ City:_____________________ State:_____ Zip:___________
Emergency Contact:
Name:_________________________________________________ Relationship to Patient:__________________________________ Home #:_____________________________ Cell #:______________________________ Work #:____________________________
Person Responsible for Payment (If different from above):
Name:_________________________________________________ Relationship to Patient:__________________________________ Address:__________________________________________ City:_____________________ State:_________ Zip:_______________ Street/Apt #/PO Box
Home #:_____________________________ Cell #:______________________________ Work #:____________________________ Email:____________________________________________ SSN#:_________________________ Date of Birth:_________________
Primary Insurance Information: **Please present your ID & Insurance Cards at every visit**
Insurance Co.:____________________________________________________________ Phone #:____________________________ Name of Insured:_________________________________ Date of Birth:______________ Relationship to Patient:_________________ Policy #:________________________________________ Group #:____________________________________
Secondary Insurance Information:
Insurance Co.:____________________________________________________________ Phone #:____________________________ Name of Insured:_________________________________ Date of Birth:______________ Relationship to Patient:_________________ Policy #:________________________________________ Group #:____________________________________
Procedure Price List
Welcome to North Dallas Dermatology Associates. We are honored to be a part of your healthcare team.
*Please note that you may disregard this notice if you are a Medicare recipient.
Many dermatology procedures go towards your deductible. Please be aware that if you have one of these procedures done, we collect an estimated payment on a few of these procedures at the time of check out. Should your insurance pay these procedures in full, we will refund your payment upon receipt of your insurance payment.
For your convenience and because we know that no one likes a surprise, we have listed below the most common procedures done i n this office which normally go towards your deductible.
Biopsy of a skin lesion
o One lesion $96.00 1st
$30.00 each additional
Destruction of actinic keratosis/precancerous lesions $75.00-$175.00
Destruction of a wart, molluscum, or other benign lesion $102.00-$125.00
Excision of a skin lesion on the trunk, genitalia, arms and legs $90.00-$327.00
Excision of skin lesion on the scalp, neck, hands and feet $90.00-$245.00
Excision of skin lesion face, ears, eyes, nose and lips $98.00-$385.00
Surgical repair of the above listed skin lesion(s) $185.00-$425.00
__________________________________ ____________________
Name of Patient Date
__________________________________ ____________________ Signature of Patient or Responsible Party Date of Birth
Authorization for Use and Disclosure of Protected Health Information
I hereby authorize North Dallas Dermatology Associates to use and/or disclose my protected health information as described below to: Name and relationship to recipient(s):
For the following purposes: (describe each purpose of use/disclosure – If disclosing different types of information below for different purposes, the authorization must specify the purpose for which each type of information is being disclosed.)
I understand that:
1) THIS AUTHORIZATION IS VOLUNTARY AND I MAY REFUSE TO SIGN THIS AUTHORIZATION WITHOUT AFFECTING MY HEALTH CARE OR THE PAYMENT FOR MY HEALTH CARE
2) I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used and/or disclosed under this authorization (if allowed by state and federal law. See 45 CFR § 164.524).
3) I may revoke this authorization at any time by notifying North Dallas dermatology Associates in writing as set forth in the Notice of Privacy Practices. However, it will not affect any actions taken before the revocation was received or actions taken in reliance thereon, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer with the right to contest a claim under the policy.
4) North Dallas Dermatology Associates agrees to maintain the confidentiality of my protected health information; however, if the person or organization authorized to receive the information is not a health plan, health care clearinghouse or health care provider, federal law (HIPAA) requires me to be advised that information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by HIPAA rules.
Marketing:
If this box has been checked by the practice, I understand that the practice will receive compensation for using or disclosing my information for marketing purposes.
Type of information to be disclosed:
Entire Medical Record Most Recent 5 Year History Radiology Reports
Office Chart Notes All Hospital Records Operative Reports
Billing Statements Transcribed Hospital Reports Other:
Dental records History and Physical Exam
Laboratory Reports Emergency and Urgent Care Records
Pathology reports Medical Records for Continuity of Care
Consultation Diagnostic Imaging Reports
Discharge Summary Emergency Room Reports
In addition, I authorize that this will include health information relating to (check if applicable):
HIV/AIDS infection Drug/Alcohol abuse Genetic Testing
Patient Name: Patient ID #:
Signature of Patient or Legal Representative (if applicable) Date
Relationship to Patient (If applicable)
Parent or guardian of unemancipated minor Printed Name of Patient’s Representative (If applicable) Court appointed guardian
Executor or administrator of decedent’s estate Power of Attorney
Acknowledgement of Receipt of Notice of Privacy Practices
Patient Name: Patient DOB:
I hereby acknowledge that I have received a copy of North Dallas dermatology Associates’ Notice of Privacy Practices. I understand that I have the right to refuse to sign this acknowledgement if is so choose.
Signature of Patient or Legal Representative (if applicable) Date
Relationship to Patient (If applicable) Parent or guardian of unemancipated minor
Printed Name of Patient’s Representative (If applicable) Court appointed guardian
Executor or administrator of decedent’s estate Power of Attorney
FOR OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices on the following date, but acknowledgment could not be obtained because:
Patient/representative refused to sign
Emergency situation prevented us from obtaining acknowledgment at this time (Will attempt again at a later date)
Communication barriers prohibited obtaining acknowledgment (Explain)
Other (Specify)
Financial Policy
Thank you for selecting our practice for your dermatological needs. Our goal is to provide you with the highest quality of treatment and service. Your complete understanding of your financial responsibilities is an essential element of your care. If you have any questions about the following policy, please do not hesitate to ask our staff.
Patients are responsible for payment at the time of service. However we do accept Cash, Checks, MasterCard, Visa, Discover and
Care Credit. We DO NOT accept AMEX.
We are contracted providers with many insurance plans and will accept assignment of benefits. As a courtesy, we will file all claims, including secondary insurance, to the plans with which we participate. Please inform us of any special requirements in your plan. You are responsible to pay for any co-payments, applicable dermatology procedures, Levulan (if applicable) or cosmetic treatments at the time of each visit. Many dermatology procedures go toward your deductible. Please be aware that we collect an estimated payment on a few of these procedures at the time of check out (please refer to our Procedure Price List for details). Should your insurance pay these procedures in full, we will refund your payment upon receipt of your insurance payment. You are req uired to pay the deductible or co-insurance amounts designated by your insurance company. If your insurance company denies your bill, you will be billed directly for those services and are held financially responsible.
In the event your health plan determines a service to be “not covered,” or you do not have an authorization, you will be responsible for the complete charge. We encourage our patients to understand their policy and to contact their plan for clarification of benefits prior to services being rendered.
In addition, if you have coverage with an insurance plan that we do not contract with, we will prepare a receipt for you at the time of service with all the necessary information needed for you to file the claim. All charges for your care and treatment are due at the time of service for these health plans.
You must inform the office of all insurance changes, authorization referral requirements, and address changes. In the event the office is not informed before care is rendered, you will be responsible for any charges that are denied.
In cases of divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those charges. If the divorce decree requires the other parent to pay all or part of the costs, it is the authorizing parent’s responsibility to collect from the other parent.
You may receive a separate bill for laboratory or pathology services from an off-site lab for any tests your physician may order. Please discuss any billing errors or discrepancies with that laboratory.
Other Miscellaneous Fees Cancellation, Missed Appointments and Late Arrivals
If you need to cancel an appointment, we kindly request that you allow at least 24-hour notice so that your appointment may be given to another patient who may be in need of urgent care. If we do not receive 24-hour notice there will be a $30.00 cancellation fee billed. Patients with multiple cancellations or missed appointments also may be discharged from our practice. In an event you are running late, please call our office. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule.
Returned Check Fee There will be a $30.00 charge for all returned checks.
Collection Fee If your account is turned over to our collection agency, you will be responsible for the collection fee charged to us by the agency in addition to your outstanding balance
I have read and understand the financial policy, and I agree to be bound by its terms. I understand and agree that such terms may be amended in the future by the practice.
Signature of Patient or Responsible Party Date
Optional
Credit Card Save on File
For your convenience and as an option, we kindly request that you leave a credit card on file which may be used to reduce your remaining balance after insurance pays. Please complete and sign the following:
Credit Card Authorization
I authorize North Dallas Dermatology Associates to bill my insurance for the
Initials services rendered today. Upon receipt of payment from my insurance company, I authorize North Dallas Dermatology Associates to charge the below listed credit card in the amount of the remaining unpaid balance.
I understand that cosmetic procedures are not billed to my insurance. Should
Initialsthere be a remaining balance on cosmetic services, I authorize North Dallas
Dermatology Associates to charge the below listed credit card in the amount
of the remaining unpaid balance.
An email will be sent to notify me of the additional charge to my credit card.
Initials
Patient Name Patients Date of Birth
Credit Card Billing Address:
_______________________________
Address line 1
_______________________________
Address line 2
_______________________________ ___________________________
City, state, zip code Card holders Email address
_______________________________ Best number to be reached
__________________________ _____________________ Name as it appears on credit card Last four numbers on credit card Credit card expiration date
______________________________ ___________________________ Credit card holder authorizing signature Date
OFFICE USE ONLY:
Employee initials: _________
NAME
______________________________________________DATE
_______________________Endocrine □ No to All Gastrointestinal
□ No □ Yes Thyroid problems □ No □ Yes Nausea or vomitting □ No □ Yes
□ No □ Yes Excessive thirst □ No □ Yes Heartburn □ No □ Yes
□ No □ Yes Eyes □ No to All Increasing constipation □ No □ Yes
□ No □ Yes Redness □ No □ Yes Persistant diarrhea □ No □ Yes
□ No □ Yes Pain □ No □ Yes Blood in stool or black stool □ No □ Yes
□ No to All Double vision □ No □ Yes Tightness or abdominal pain □ No □ Yes
Problems with healing □ No □ Yes Blurred vision □ No □ Yes Jaundice □ No □ Yes
Problems with scarring □ No □ Yes
Easy bruising □ No □ Yes Ears/Nose/Mouth/Throat□ No to All Genitourinary
Redness □ No □ Yes Ringing in ears □ No □ Yes Pain/burning on urination □ No □ Yes
Rash □ No □ Yes Runny nose □ No □ Yes Blood in urine/cloudy, □ No □ Yes
Hives □ No □ Yes Sores in mouth □ No □ Yes Smoky urine □ No □ Yes
Itching □ No □ Yes Dryness in mouth □ No □ Yes Discharge from penis/vagina □ No □ Yes
Sun sensitive □ No □ Yes Frequent sore throat □ No □ Yes Getting up at night to pass urine □ No □ Yes
Tightness □ No □ Yes Difficulty swallowing □ No □ Yes Vaginal dryness □ No □ Yes
Nodules/bumps □ No □ Yes Hoarseness □ No □ Yes Rash/ulcers in genital area □ No □ Yes
□ No □ Yes □ No □ Yes
□ No to All Cardiovascular □ No to All Musculoskeletal
Frequent sneezing □ No □ Yes Sudden onset chest pain □ No □ Yes Morning stiffness □ No □ Yes
Susceptibilty to infection □ No □ Yes Sudden changes of heart beat □ No □ Yes Joint pain □ No □ Yes
Immunosuppression □ No □ Yes High blood pressure □ No □ Yes Muscle weakness □ No □ Yes
Hay fever □ No □ Yes Swollen legs or feet □ No □ Yes Muscle tenderness □ No □ Yes
Joint swelling □ No □ Yes
□ No to All Respiratory □ No to All Neuroligical/Psychiatric
Fever, chills or shakes □ No □ Yes Cough □ No □ Yes Headaches □ No □ Yes
□ No □ Yes Shortness of breath □ No □ Yes Dizziness □ No □ Yes
□ No □ Yes Wheezing □ No □ Yes Fainting □ No □ Yes
□ No □ Yes Anxiety □ No □ Yes
Depression Agitation
ALERTS
ALERTS
Allergy to: Artificial Heart Valve □ No □ Yes Pacemaker □ No □ Yes
Adhesive □ No □ Yes Artificial joints within 2 years □ No □ Yes MRSA/Staph □ No □ Yes
Lidocaine □ No □ Yes Blood Thinners □ No □ Yes Premedication Prior to Procedures □ No □ Yes
Topical Antibiotic Ointments □ No □ Yes Defibrillator □ No □ Yes Rapid Heartbeat with Epinephrine □ No □ Yes
Are you pregnant? □ No □ Yes Planning on becoming pregnant soon? □ No □ Yes
Are you breastfeeding? □ No □ Yes Are you on some form of birth control? □ No □ Yes If yes, what form?_____________
PREGNANCY AND CHILDBEARING INFORMATION FOR WOMEN ONLY
ALERTS
PLEASE CHECK YES OR NO IN THE BOX PROVIDED FOR ALL SYMPTOMS YOU ARE CURRENTLY EXPERIENCING
REVIEW OF SYSTEMS AND ALERTS
□ No to All
Night sweats
Unintentional weight gain Unintentional weight loss Color changes - hands/feet Hair loss Anemia Tender glands Swollen glands Transfusion □ No to All Constitutional □ No □ Yes □ No □ Yes Hematologic/Lymphatic
Problems with bleeding
□ No to All
□ No to All □ No to All
Integumentary - Skin
