Patient Data Package Jan 27, 2021 Order Number Today's Date * Patient Date Of Birth * First Name * Middle Initial Last Name * Email Address * Home Number * Work Number Cell Number May we leave messages with medical information at the numbers listed above? * Yes No Gender * Male Female Marital Status * Divorced Married Single Widowed SSN * Occupation Employer Emergency Contact Relation To Patient Contact Number Any family members who are patients here? If so, please list Who is responsible for this account? * Contact Number * Street * City * State * Zip Code * Medical History Are you allergic to any medications? * Yes No If yes, please list Any other Allergies? * Yes No If yes, please list Are you taking any medications? (Prescribed/Over the Counter) * Yes No If yes, please list What is your preferred Pharmacy? Pharmacy Location Who is your Primary Care Physician? Physician Contact Number Are you seeing any other Physicians at this time? If so, please list Do you or any family member have a history of skin cancer? If so, who and what kind? General medical history HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT USES AND DISCLOSURES OF HEALTH INFORMATION TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS Senter Dermatology uses and discloses your protected health information for treatment, payment and health care operations. Some examples of when our office may use or disclose your health care information for these purposes include: Sharing test results with other health care provider for confirmation of diagnosis; Providing your diagnosis or other information about your health to your insurance provider or our billing service to obtain payment for the health care services we provide; Reviewing information as part of our quality improvement program. Other Uses and Disclosures Senter Dermatology may also use or disclose your protected health information, in compliance with guidelines outlined by law, for the following purposes: Provide you with information related to your health; Contacting you regarding appointments, information about treatment alternatives, or other health related services; Incidental uses or disclosures (e.g., listing your name on a sign in sheet, etc.); Compliance with all laws (including reports of suspected abuse, neglect or violence); Providing certain specified information to law enforcement or correctional institutions; Providing information to a coroner, medical examiner, funeral director, or organ procurement organization; Public health activities when requested by public health authority or the FDA; Responding to health oversight agencies; Responding to court or administrative tribunal orders, subpoenas, discover request or other lawful process; Research activities; When necessary to avert a serious threat to health or safety; Military affairs, veterans’ affairs, national security, intelligence, Department of State, or presidential protective service activities; Providing information regarding your location, general condition or death to public or private disaster relief agencies; Informing a family member, other relative or close personal friend when: Information is relevant to the individual’s involvement with your care; To assist in your health care (e.g. pick-up prescription or other documents, note follow up care instructions, etc.). Authorization for Other Uses Senter Dermatology will make other uses or disclosure of your protected health information only after obtaining your written authorization. If you authorize a use not contained in this notice you may revoke your authorization. Your Rights Regarding the Privacy of your Health Information Subject to limitations outlined by law, you have certain rights related to use and disclosure of your protected health information, including the right to: Request restrictions on certain uses or disclosures. However, Senter Dermatology is not obliged to agree to requested restrictions. Receive confidential communications of protected health information. Inspect and copy your protected health information with some limited exceptions. Amend your health information. Receive an accounting of disclosures of your health information. Obtain a copy of this notice. Senter Dermatology Regarding the Privacy of your Health Information Subject to limitations outlined by law, Senter Dermatology has certain duties related to your protected health information, including: Senter Dermatology is required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. Senter Dermatology is required to abide by the terms of the privacy notice that is currently in effect. Senter Dermatology reserves the right to change a privacy practice described in this notice and to make such change effective for all protected health information. Revised notice will be posted in our office and available upon request. Concerns If you believe your privacy rights have been violated, you may make a complaint by contacted Senter Dermatology or the Secretary for the Department of Health and Human Services. NO individual will be retaliated against for filing a complaint. Acknowledgement I acknowledge that I received a copy of this notice regarding the use and disclosures of my health information. BILLING POLICIES PLEASE INITIAL EACH LINE Initials * Senter Dermatology cannot accept new patients on Medicare or Medicaid, we are not an authorized Tricare provider, nor do we participate in Workman’s Compensation claims. SENTER DERMATOLOGY CANNOT BILL AND IS NOT CONTRACTED WITH MEDICAID, TRICARE, VA, CHAMPUS, OR DENALI KIDCARE. Initials * Senter Dermatology cannot bill insurance nor seek prior-authorizations for preventive health care services and most cosmetic services. Initials * I agree to pay my office co-pay amount (if applicable) and 20% of any remaining amount owed at the time of my visit. I have been given the opportunity to pay my estimated deductible and coinsurance at the time of service. I authorize my insurance company to pay my benefits directly to Senter Dermatology and I understand that I will be fully responsible for any outstanding balance on my account. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional charges over and above the insurance payment. I have chosen to assign benefits, knowing that the claim must be paid within all state or federal prompt payment guidelines. I will provide all relevant and accurate information to facilitate the prompt payment of the claim by my insurance company. Initials * I am aware that I am responsible for any balance from any procedures/treatments that have been denied (especially that involve Botox® or lasers), REGARDLESS if my insurance company has stated that they approve said procedures/treatments. Initials * I am aware that if more than three appointments are missed, or if I fail to contact Senter Dermatology in a timely fashion to cancel or reschedule an appointment, the provider may decide to discontinue care. Initials * I am aware that it is my responsibility to respond to mailed or phone requests for follow up. Failure to respond in a timely manner to mailed or phone messages regarding my follow up may result in my discharge from Senter Dermatology. Initials * I am aware that I am responsible for providing accurate and complete insurance information. I am aware that it is my responsibility to contact the insurance company if a claim is thirty days or more past due, to pay all outstanding balances after sixty days, regardless of whether or not the insurance has made a determination on the claim. I am also aware that it is my responsibility to promptly pay any balance remaining after the insurance finalizes the claim and to promptly respond to any questionnaires or updates sent out by the insurance company regarding coverage so as not to delay claim payment. If I fail to supply an insurance company with requested information, the account will be turned over to a collection agency immediately. If I cannot provide my insurance card at the time of visit, I will pay IN FULL and will be given the proper paperwork to submit to insurance myself. Initials * I authorize, Senter Dermatology, to release any information necessary to adjudicate the claim, and understand that there may be associated costs for providing information beyond what is necessary for the adjudication of a clean claim. Initials * I also understand that should my insurance company send payment to me directly, I will forward the payment to Senter Dermatology within 72 hours. I agree that if I fail to send the payment to Senter Dermatology and they are forced to proceed with the collections process; I will be responsible for any cost incurred by the office to retrieve their monies. Any violations of this agreement will, at the provider’s election, terminate patient charge privileges with Senter Dermatology and bring any balance owed by me, the patient, to Senter Dermatology to be due and payable immediately. Initials * I authorize, Senter Dermatology, to initiate a complaint or file an appeal to the insurance commissioner or any payer authority for any reason on my behalf, and I personally will be active in the resolution of claims delay or unjustified reductions or denials. Initials * I understand that all services rendered to me by the providers at Senter Dermatology are my financial responsibility, and that the provider will bill my insurance company as a courtesy. First Name * Last Name * Email Address * Today's Date * INSURANCE INFORMATION If you do not have the following information readily available at the time of your visit you will be asked to pay your visit in full. Please present card to front desk. We only submit to a maximum of two insurances. Proper paperwork can be given to you to submit to any remaining insurances yourself. PRIMARY INSURANCE Insurance Company Name * Insurance Phone * Insurance Company Address Address * City * State * Zip Code * Insurance Identification Number With Prefix * Insurance Group Number * Subscriber Name * Subscriber Date of Birth * Subscriber Address Address * City * State * Zip Code * Subscriber SSN Subscriber Contact Number * Subscriber’s Relationship to the Patient * Self Spouse Parent/Guardian Other If Other, What Relationship To Patient SECONDARY INSURANCE Insurance Company Name Insurance Phone Insurance Company Address Address City State Zip Code Insurance Identification Number Insurance Group Number Subscriber Name Subscriber Date of Birth Subscriber Address Address City State Zip Code Subscriber SSN Subscriber Contact Number Subscriber’s Relationship to the Patient Self Spouse Parent/Guardian Other If Other, What Relationship To Patient I attest that the above information is accurate and I understand Senter Dermatology’s office policies.