Name

Today's Date *

Patient Date Of Birth *

Patient First Name *

Patient M.I.

Patient Last Name *

Street *

City *

State *

Zip Code *

Email Address *

Home Number *

Work Number

Cell Number

May we leave messages with medical information at the numbers listed above? *

Yes

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 *

Please list the name(s) and phone number(s) of all those that you give us permission to speak to regarding your care here

Medical History

Are you allergic to any medications? *

Yes

If yes, please list

Any other Allergies? *

Yes

If yes, please list

Are you taking any medications? (Prescribed/Over the Counter) *

Yes

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

First Name *

Middle Initial

Last Name *

Relationship to Patient *

Past Medical History: Check All That Apply

ALLERGY/IMMUNO.

Food Allergy

Hay Fever

Lupus

Rheumatoid Arthritis

Scleroderma

Vasculitis

CARDIO-VASCULAR

High Cholesterol

High Triglycerides

Hypertension

Heart Attack

Blood Clots/DVT

SKIN

Acne

Eczema

Herpes

Keloids

Melanoma

Skin Cancers

Warts

Ulcers

Cold Sores

GE/GU

Hemorrhoids

Hiatal Hernia

Hepatitis

Stomach Ulcer

Renal failure/dialysis

Kidney Stones

EYES/NOSE/EARS

Cataracts

Glaucoma

Deafness

Sinus issues

PULMONARY

Asthma

Emphysema

Tuberculosis

PSYCHIATRIC

Anxiety

Depression

Dementia

MUSCULO-SKEL

Arthritis

Injury

ENDOCRINE

Diabetes

Hypothyroid

BLOOD

Anemia

Transfusions

NEUROLOGIC

Stroke

Dementia

Other

Systems Review: Check All That Apply

GENERAL

Appetite change

Chills

Dizziness

Excess Thirst

Fatigue

Fever

Night Sweats

Nausea or Vomiting

Weight Change

CARDIO-VASCULAR

Chest pain/tightness

Heart Murmur

Legs Swelling

Palpitations

ENT

Bleeding Gums

Dry Mouth

Mouth Ulcers

Sinus Drainage

Hard Of Hearing

Ringing In Ears

Blood In Urine

Discharge

Painful Urination

ALLERGY/IMMUNO.

Watery eyes

Sneezing

PSYCHIATRIC

Memory problems

Panic attacks

Suicidal thoughts

Suicide attempt

Anxiety

Depression

Dementia

PULMONARY

Shortness of breath

Wheezing

EYES

Dry eyes

Yellowing of eyes

Eyes

Dry eyes

Light sensitivity

Yellowing of eyes

Black/bloody stools

Constipation

Diarrhea

Heartburn

Stomach pain

Trouble swallowing

ENDOCRINE

Abnormal hair growth

Flushing

Menstrual problem

MUSCULO-SKEL

Back pain

Joint pains

Joint swelling

Leg cramps

NEUROLOGIC

Blackouts

Headaches

Numbness

HEMATOLOGIC

Bleeding tendencies

Easy bruising

Swollen lymph node(s)

Anemia

SKIN

Blisters

Itching

Lesions/growths

Nail changes

Pigment loss

Sun sensitivity

Changing moles

OTHERS

X-ray therapy

Chemotherapy

Blood borne illness or sexually transmitted disease? (Check all that apply)

HIV/AIDS

Hepatitis

Herpes

Other

If Herpes?

Genital

Oral

If Other, please describe?

Surgical History (Check all that apply)

Require antibiotics before procedures?

Pacemaker/Defibrillator

CABG (Bypass)

Heart valve repair or replaced: Left/Right

Knee replacement: Left/Right

Hip replacement

Appendectomy

Hysterectomy

Other

Social History

Smoke: number of packs/day?

Drink alcohol: number of drinks/day?

Recreational Drugs?

FEMALES ONLY

Are you pregnant?

yes

Trying to conceive?

yes

Breastfeeding?

yes

On hormonal replacement therapy?

yes

FAMILY HISTORY: CHECK ALL THAT APPLY

(RELATION EXAMPLE: Mother, Father, Grandmother/Father)

Diabetes

yes

Diabetes Relation

High Cholesterol

yes

High Cholesterol Relation

Cancer

yes

Cancer Relation

Asthma

yes

Asthma Relation

Eczema

yes

Eczema Relation

Arthritis

yes

Arthritis Relation

Basal Cell Skin Cancer

yes

Basal Cell Skin Cancer Relation

Squamous Cell Cancer

yes

Squamous Cell Cancer Relation

Melanoma

yes

Melanoma Relation

Lupus

yes

Lupus Relation

Hypertension

yes

Hypertension Relation

Heart Disease

yes

Heart Disease Relation

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 *

If Other, What Relationship To Patient

I attest that the above information is accurate and I understand Senter Dermatology’s office policies.

Patient Data Sheet – Dr. Miller

Patient Data Sheet – Dr. Miller

Medical History

Past Medical History: Check All That Apply

Systems Review: Check All That Apply

Social History

FEMALES ONLY

FAMILY HISTORY: CHECK ALL THAT APPLY

(RELATION EXAMPLE: Mother, Father, Grandmother/Father)

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

BILLING POLICIES

PLEASE INITIAL EACH LINE

INSURANCE INFORMATION

PRIMARY INSURANCE

Insurance Company Address

Subscriber Address

Patient Data Sheet – Dr. Miller

Medical History

Past Medical History: Check All That Apply

Systems Review: Check All That Apply

Social History

**FEMALES ONLY**

FAMILY HISTORY: CHECK ALL THAT APPLY

(RELATION EXAMPLE: Mother, Father, Grandmother/Father)

FEMALES ONLY