New Patient Intake Form

Advanced Dermatology & Skin Cancer Institute

15477 Ventura Blvd., Suite 100, Sherman Oaks, CA 91403 | 28049 Smyth Dr. Valencia, CA 91355 | 2659 Townsgate Rd., Suite 215, Westlake Village, CA 93036 | 416 N. Bedford Dr., Suite 100, Beverly Hills, CA 90210
RE: Electronic Patient Communication

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created several guidelines for doctors to follow to encourage Electronic Patient Communication. A new requirement is the creation of a patient portal for doctor’s offices to communicate safely and securely following Health Insurance Portability and Accountability Act of 1996 (HIPAA) guidelines.

Our office has an advanced Electronic Health Record (EHR) system that provides a patient portal called Patient Ally.

Please provide your email below so that we can enroll you in Patient Ally and assign you a temporary password. The temporary password is “DrLin123!”. Please be sure to log in and change your temporary password at your earliest convenience.

Thank you for assisting us in fulfilling this important MACRA requirement.

Sincerely,

Dr. Lin
Please print your email address in blocks above in all CAPS. *
example@example.com
We value your privacy. Please let us know your preference.

I wish to receive emails directly related to my medical care. I agree to allow Michael Lin, MD and his associates to email me information related to my medical care. I agree to allow Michael Lin, MD and his associates to enroll me in Patient Ally.
I do not wish to receive promotional and informational emails regarding news, events, and specials from Dr. Lin.
Patient Signature *

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Date *

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ELECTRONIC PATIENT COMMUNICATION.docx Last modified 3/23/2018

Financial Policy
In order to establish optimal customer service and avoid misunderstandings or confusion regarding our payment policies, please be sure to inquire about our financial policy at our reception area. Payment is required for all services as rendered. Due to individual skin characteristics, we are unable to guarantee results from any product, procedure, or service. Sales and final and no refunds will be issued. If you wish to participate in any of the financial or promotional plans offered by this office, please discuss with a corresponding consultant prior to treatment. Patients must pay applicable co-payments, cosmetic balances and deductibles on the date of visit. We accept payment in the form of cash, check, credit card or debit card.

Your signature below signifies your understanding and willingness to comply with the policy.
Signature of Patient / Responsible Party *

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Name of Patient / Responsible Party: *

First Name Last Name
Date: *

Month Day Year
Date
Relationship to Patient:

PAYMENT POLICY
Thank you for choosing our medical practice. We are committed to providing you the best possible medical care. The following information is provided to avoid any confusion regarding payment for professional medical services. Our Insurance Billing Department will work with you to see that your claim is filed accurately and promptly.

●All deductibles and copayments will be collected in full at the time of service.

●If we are in-network with your insurance plan, we will not discount our services by any further amount after your insurance company has processed your claim and informed us of your responsibility.

●If we are not a contracted provider for your insurance company, we will bill them, as a courtesy, on your behalf.

●It is our preference to establish a credit card payment plan that we will use for settlement of all your account balances. (Optional)
I authorize the Advanced Dermatology and Skin Care Institute to charge outstanding balances on my account to the credit card provided. (For security purposes, you will have the option to write in your Credit Card information by hand after printing this PDF, or provide credit card details in-person).
Signature:

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Date:

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Please sign below that you have read and agree to this Policy.

●PLEASE NOTE: Unpaid account balances will be assessed a $10.00 re-billing fee for each statement generated after 90 days have passed. Late fees will begin accruing after 90 days.

●If your account is overdue for more than 120 days after your insurance has paid, it will be referred to a collection agency. This is done reluctantly, as a last resort, after we have exhausted all efforts for voluntary payment.

●New Patients, and those who have no insurance, are required to pay at the time of service with either a credit card or cash. We do not accept personal checks.

●Chemical Peels are no longer covered by most insurance companies.
Acknowledgement and Authorization:

I have read, understand and agree to abide by the above payment policy. I understand that charges not covered by my insurance company, as well as copayment, deductibles and coinsurance, are my responsibility.

I authorize my insurance benefits to be paid directly to: Michael T. Lin, M.D.

One-Time Authorization For Medicare recipients:

I request that my payment of authorized Medicare benefits be made to me on my behalf to Michael T Lin MD, Inc for any services furnished me. I authorize holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. Additionally, I request that payment of authorized Medi-gap benefits be made to either me or on my behalf to Michael T. Lin MD., Inc. for any services furnished by this provider. I authorize any benefits or the benefits payable for related services.
PATIENT/ GUARDIAN SIGNATURE: *

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DATE: *

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PRINT PATIENT/ GUARDIAN NAME: *
RELATIONSHIP TO PATIENT: *

ACKNOWLEDGEMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES
Our office has copies of the HIPAA Notice of Privacy Practices available. Please feel free to get a copy or ask a staff member to hand one to you. I have read/understand the full Notice of Privacy Practices.
Patient Name: *

First Name Last Name
*

I have read/understand the full Notice of Privacy Practices:
Name of Patient / Responsible Party: *

First Name Last Name
Signature of Patient / Responsible Party: *

Clear
Relationship to Patient:
Date: *

Month Day Year
Date
ACKNOWLEDGMENT: OFFICE POLICY FOR NO SHOW PATIENTS
No Show Policy

Please notify our office 48 hours in advance if you are unable to keep your scheduled appointment. If you do not notify us and miss your appointment by not showing up at all, we will require that you pay a $75.00 Missed Appointment Fee before we will book you another office visit.
Patient Name: *

First Name Last Name
*

I have read/understand the full Office Policy for No Show Patients.
Name of Patient / Responsible Party: *

First Name Last Name
Signature of Patient / Responsible Party: *

Clear
Date: *

Month Day Year
Date
Relationship to Patient:
Should be Empty:

Advanced Dermatology & Skin Cancer Institute

PATIENT INFORMATION

Race

Ethnicity

Allergies

Current Medications

Financial Policy

MEDICAL QUESTIONNAIRE

Past Surgeries:

Social History

PAYMENT POLICY

ACKNOWLEDGEMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGMENT: OFFICE POLICY FOR NO SHOW PATIENTS