NEW PATIENT INFORMATION

PATIENT INFORMATION
LAST NAME
FIRST
MIDDLE
PATIENT DOB

Month Day Year
Date
SEX
MARITAL STATUS
SSN#
PREF LANGUAGE
RACE
ETHNICITY
CITY OF BIRTH
COUNTRY OF BIRTH
EMERGENCY CONTACT NAME
EMERGENCY CONTACT NUMBER
Preferred Phone Number *

Home Work Cell
HOME PHONE
WORK PHONE
CELL PHONE
EMAIL
example@example.com
ALT EMAIL
example@example.com
MAILING ADDRESS
APT#
CITY
STATE
ZIP CODE
EMPLOYER/SCHOOL
HOW WERE YOU REFERRED?
PRIMARY PHYSICIAN
PRIMARY PHYSICIAN PHONE
PHARMACY
RESPONSIBLE PARTY INFORMATION

Complete the following if Patient is a Minor
Is the patient a Minor? *

Yes No
FIRST/LAST NAME
RELATIONSHIP
DATE OF BIRTH

Month Day Year
Date
SSN#
HOME PHONE
WORK PHONE
ADDRESS
FATHER NAME (of minor)
MOTHER NAME (of minor)
LEGAL GUARDIAN NAME (of minor)
INSURANCE INFORMATION
Do you currently have insurance? *

Yes No
PRIMARY INSURANCE COMPANY
Group Number
Policy Number
Subscriber
Subscriber DOB

Month Day Year
Date
Relation to Patient
Address (if different than patient)
Proof of Insurance - Front of Insurance Card *

Browse Files
Upload a picture of your insurance card. Cancel of
Proof of Insurance - Back of Insurance Card *

Browse Files
Upload a picture of your insurance card. Cancel of
Driver's License *

Browse Files
Upload a picture of your Driver's License. Cancel of
Do you have a Secondary Insurance Provider? *

Yes No
SECONDARY INSURANCE COMPANY
SECONDARY Group number
SECONDARY Policy number
SECONDARY Subscriber
Subscriber DOB

Month Day Year
Date
Relation to patient
Address (if different than patient)
Proof of Insurance - Front of Insurance Card *

Browse Files
Upload a picture of your insurance card. Cancel of
Proof of Insurance - Back of Insurance Card *

Browse Files
Upload a picture of your insurance card. Cancel of
PLEASE INITIAL EACH SECTION BELOW TO INDICATE YOU HAVE READ AND UNDERSTAND THE INFORMATION
ASSIGNMENT OF INSURANCE AND FINANCIAL RESPONSIBILITY *
I do, hereby authorize payment of my insurance benefits, including authorized Medicare benefits, basic and major medical for the services I receive, to be made directly to Coastal Skin Surgery and Dermatology.
CONSENT FOR MEDICAL SERVICES *
I authorize Coastal Skin Surgery and Dermatology to render treatment to me or my dependents for dermatological care or medical procedures as deemed medically necessary for treatment as indicated.
REFERRALS/AUTHORIZATIONS *
I understand that if my insurance requires a referral or an authorization, I am responsible for obtaining the referral prior to my visit. If I do not have a referral or authorization at the time of my visit, I may be rescheduled or sign a waiver of financial responsibility. In such case I understand that full payment will be required at the time of service.
FINANCIAL RESPONSIBILITY *
I understand that although Coastal Skin Surgery and Dermatology will file a claim to my insurance plan(s), I am expected to pay my copayment, coinsurance, deductible and non-covered services amounts at the time services are rendered. I acknowledge that Coastal Skin Surgery and Dermatology does not guarantee payment of my claim by my insurance plan and that it is my responsibility to know the provisions of my insurance. Not all procedures are deemed “Medical Necessity” by insurance carriers and can be considered cosmetic. For example-Skin tag removal, correction of dark spots, yearly skin cancer screenings without specific areas of concern, would not be a covered service. I understand that I would be responsible for payment of such services. I am ultimately responsible for any unpaid balance or non-covered service. I agree to pay all costs of collecting, securing or attempting to collect or secure payment, including reasonable attorney fees or collection agency fees. I also understand that any prior unpaid balances on my account must be paid in full before being seen by a provider. If my prior balance cannot be paid in full, I will speak with a financial counselor at Coastal Skin Surgery and Dermatology to make a payment arrangement before services can be rendered. I also understand that if Coastal Skin Surgery and Dermatology does not participate with my insurance plan that I will be expected to pay in full for my services. And it is my responsibility to know if Coastal Skin Surgery and Dermatology is in network with my insurance plan. I understand that payments to Coastal Skin Surgery and Dermatology can be made by cash, checks and all major credit cards. I also acknowledge that returned checks will be subject to a non-sufficient fund fee of $25.00.
COSMETIC SERVICES *
Cosmetic services are not a covered benefit under insurance plans. I understand that to make an appointment for cosmetic services, I will be expected to pay half of the service as a down payment and be expected to pay the remaining balance when services are rendered.
PATIENT RESPONIBILITY *
I understand that due to Federal (red flag) rules that Coastal Skin Surgery and Dermatology is prevented from filing to my insurance without proof of identification. I will be expected to present a photo ID and insurance card(s) at every office visit. I will also update any changes to my addresses, telephone numbers and insurance if they have changed since my last visit and I understand that I will be asked to update my demographics and signatures annually.
MISSED APPOINTMENTS *
It is my responsibility to notify Coastal Skin Surgery and Dermatology at least 48 hours prior to my appointment if I am unable to keep the appointment. I acknowledge that if I miss two appointments without sufficient notification that I will be charged a $50 fee. If I miss three appointments without sufficient notification, I will be dismissed from the practice for non-compliance.
PRIVACY POLICY NOTICES *
I have been offered a copy of Coastal Skin Surgery and Dermatology’s Notice of Privacy Policies that details how my personal health information may be used, disclosed and my rights as permitted by federal law. As well I understand that this notice is posted for my benefit in the reception areas and on the website of Coastal Skin Surgery and Dermatology.
ePRESCRIBING CONSENT *
I acknowledge that Coastal Skin Surgery and Dermatology utilizes electronic health records and will transmit my prescriptions electronically as permitted to the pharmacy that I designate as my pharmacy provider. To enable electronic prescriptions to my pharmacy, I grant Coastal Skin Surgery & Dermatology my permission to access my medication history to view current and past prescription information.
LAB SERVICES *
I am aware that my laboratory/pathology services may not be billed from Coastal Skin Surgery and Dermatology. I will receive a separate statement from the lab or pathologist. In addition it is my responsibility to contact my insurance plan to determine what laboratory is in network for my plan.
PATIENT/GUARDIAN SIGNATURE:

Clear
TODAY'S DATE:

Month Day Year
Date
WITNESS:
RELEASE OF MEDICAL INFORMATION
I, by my signature below, as the patient OR his/her representative, do hereby authorize Coastal Skin Surgery and Dermatology, to release to my insurance company's or other appropriate agencies that information which is necessary to validate this claim. Coastal Skin Surgery and Dermatology, is also hereby authorized to release to my physicians, whether as an individuals or as a professional association, who perform services for me, the patient, on a fee for service basis such information as is necessary for billing purposes. I hereby authorize Coastal Skin Surgery and Dermatology, to release any medical information to physicians other than original referring providers, who may be involved in my or my dependent’s health care treatment, when requested by these physicians. By signing this consent, information will be given to requesting providers without further signed authorization. I hereby give permission to disclose, discuss and speak to listed individuals concerning my medical or financial information including, appointments, test results, prescriptions, school or work excuses, etc. We must have each individual listed by name. This includes your spouse, children, parents, etc *

RELEASE MY MEDICAL INFORMATION TO: RESTRICT/DO NOT RELEASE ANY INFORMATION
RELEASE MY MEDICAL INFORMATION TO:
Name
Phone
Relationship
May we leave personal information on your voicemail? *

Yes No
May we text personal information to your cell phone? *

Yes No
May we send personal information to your email address? *

Yes No
YOUR ACCESS TO YOUR HEALTH INFORMATION
Coastal Skin Surgery and Dermatology encourages patient involvement in their health care. Online access to health information allows patients to make informed decisions about their care and share their most recent clinical information with other health care providers and personal caregivers. You will receive an email from us following your visit today that will invite you to access our patient portal. You will be sent the link and information to go to and verify your identity. Once verified, you will be asked to set a password. You can then sign on to access your contact information, insurance and pharmacy information, skin disease history, social & family history and your problem list. Your visit notes, educational handouts and any test results related to a specific visit can be viewed also by selecting the date of your appointment. You are able to also send messages to your provider and your provider can message you in return. We are happy to answer your questions regarding access and use of your patient portal. You may choose to “opt out” or not access your information by not responding to our patient portal email and verifying your information. The link will expire 72 hours from the time it is sent to you, but you can still access the portal by your user name (your email address) and choosing “forgot password”. You may also request at any time to have your invitation resent for activation of your patient portal.

The URL to access the patient portal is: Coastalskinsurgery.ema.md Choose: “Patient Login”
The URL to access the patient portal is:
(type only the URL information-no https or www.-above and you must use either Mozilla Firefox or Google Chrome web browser.)
PATIENT/GUARDIAN SIGNATURE:

Clear
TODAY'S DATE:

Month Day Year
Date
WITNESS:
PERSONAL MEDICAL INFORMATION
PATIENT NAME
PATIENT NAME / DATE OF BIRTH

Month Day Year
Date
PREFERRED PHARMACY (Name, City, Phone)
Are you currently taking any medications? *

Yes No
CURRENT MEDICATIONS (May also Provide a list / If NONE, please write NONE)
PAST MEDICAL HISTORY (select all that apply)

Anxiety Arthritis Asthma Atrial Fib BPH Breast Cancer Colon Cancer COPD CAD/MI Depression Diabetes Kidney Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Thyroid Disease Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Tx Seizures Stroke Pneumonia Vax Flu Vax None
Do you have an Advanced Directive (Living Will)? *

Yes No
Medical Decision Maker Name:
Phone:
PAST SURGICAL HISTORY
Have you ever had a surgical procedure? *

Yes No
Organ Transplant Date

Month Day Year
Date
Organ Transplanted
Implantable Devices (Artificial Joints / Artificial Heart Valves / Pacemakers / Defibrillators) please include date(s):

Month Day Year
Date
Device Implanted
Please list any other major surgeries:
SKIN DISEASE HISTORY
Have you ever had a skin condition or skin disease? *

Yes No
Check All Applicable Skin Diseases

Acne Actinic Keratosis Dry Skin Eczema Psoriasis Flaking/Itching Scalp
Basal Cell Carcinoma (Body Location(s)/When)
Squamous Cell Carcinoma (Body Location(s)/When)
Melanoma (Body Location(s)/When)
Family History of skin cancer (which kind/family member)
ALLERGIES
Allergies (check all that apply) *

None Iodine/Seafood Latex Adhesives X-ray/VP Dye Metal/Nickel
Medication Allergies
Please List
SOCIAL HISTORY
Do you smoke cigarettes? *

No Former Smoker Yes
If yes, How many cigarettes per day?
Do you use alcohol? *

None Socially 2 - 3 Drinks a Day 4 or more Drinks per Day
Do you use a tanning bed? *

Never Past User Current User
Should be Empty:

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

PLEASE INITIAL EACH SECTION BELOW TO INDICATE YOU HAVE READ AND UNDERSTAND THE INFORMATION

RELEASE OF MEDICAL INFORMATION

RELEASE MY MEDICAL INFORMATION TO:

YOUR ACCESS TO YOUR HEALTH INFORMATION

PERSONAL MEDICAL INFORMATION

PAST SURGICAL HISTORY

SKIN DISEASE HISTORY

ALLERGIES

SOCIAL HISTORY