• Dermatology Consultants of Sacramento

    Patient Information Packet

  • PATIENT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Method of Communicate
  • May we leave detailed messages regarding test results or treatment information?
  • How did you hear about our practice?

  • Reason For Today's Visit

  • What concerns would you like addressed today? Please check all that apply:

  • DERMATOLOGY MEDICAL HISTORY

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • SKIN CANCER HISTORY

  • MEDICAL HISTORY

  • Have you ever been diagnosed with:
  • Has a first degree relative (mother, father, sibling, child) ever been diagnosed with Melanoma?

  • SUN EXPOSURE HISTORY

  • MEDICAL CONDITIONS

  • Check all that apply:

  • SURGICAL HISTORY

  • Any surgeries or hospitalizations within the last 5 years?

  • ALLERGIES

  • CURRENT MEDICATIONS

  • ADDITIONAL INFORMATION

  • Does the patient have any of the following:

  • PATIENT CONCENTS AND FINANCIAL POLICY

  • COMMUNICATION CONSENT

  • I authorize Dermatology Consultants of Sacramento to communicate with me regarding appointments, billing matters, laboratory/pathology results, and routine medical information using the methods I selected on my registration form.  I understand that text messages and email communications may not be fully secure and accept these methods for routine healthcare communications.

  • PROTECTED HEALTH INFORMATION RELEASE

  • I authorize Dermatology Consultants of Sacramento to communicate about my medical information with the following people:

  • Name
    Relation

  • Name
    Relation

  • Name
    Relation

  • HIPAA AUTHORIZATION

  • With my consent, Dermatology Consultants of Sacramento may use and disclose protected health information about me to carry out treatment, payment, and healthcare operations.  I acknowledge receipt or offering of the Notice of Privacy Practices (NPP) in accordance with HIPAA regulations (45 CFR §164.520) and Confidentiality of Medical Information Act (CMIA) and understand my rights regarding Protected Health Information.

  • Protected Health Information Release

  • Patient Printed Name

  • If, at any time, you wish to make a change, please ask us for another form.  Thank you for your cooperation.

  • OPEN PAYMENTS DATABASE NOTICE

  • The Open Payments database is a federal tool used to track payments made by drug and device companies to physicians and teaching hospitals: https://openpaymentsdata.cms.gov.

    I acknowledge receipt of this notice.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • FINANCIAL RESPONSIBILTY AGREEMENT

  • INSURANCE COVERAGE

  • As a courtesy, we will submit claims to your insurance carrier(s) when appropriate information is provided. Your insurance policy is a contract between you and your insurance company. It is your responsibility to understand your coverage, policy limitations, and to obtain referrals as required by your insurance company. Verification of benefits is not a guarantee of payment. Authorization, referral approval, or pre-certification does not guarantee coverage or payment. You are responsible for any copayments, coinsurance, deductibles, non-covered services, or other amounts determined by your insurance carrier to be patient responsibility. If your insurance information changes, it is your responsibility to notify our office before your appointment.

  • PATIENT RESPONSIBILITY

  • Payment is due at the time of service for:

    • Co-payments

    • Cosmetic consultations/procedures

    • Outstanding patient balances

    Balances remaining after insurance processing are due upon receipt of your statement.

  • PATHOLOGY AND LABORATORY SERVICES

  • Skin biopsies and certain laboratory tests may be processed by an independent pathology or laboratory provider. You may receive a separate bill directly from the pathology laboratory for these services.

  • MISSED APPOINTMENT AND LATE CANCELLATION POLICY

  • We respectfully request at least one business day's notice if you need to cancel or reschedule an appointment. Repeated missed appointments or late cancellations will result in dismissal from the practice.

  • RETURNED CHECKS AND COLLECTIONS

  • A $25 fee will be charged for returned checks or failed electronic payments. If your account becomes significantly past due, reasonable collection efforts may be initiated. You agree to be responsible for costs permitted by applicable law associated with collection of unpaid balances.

  • AKNOWLEDGEMENT

  • I acknowledge that I have read and understand this Financial Responsibility Agreement. I understand that I am financially responsible for all charges not paid by my insurance carrier or other responsible party.

  • Date of Signature
     - -
    2 digit month, 2 digit day, 4 digit year

  • Printed Name:

  • MEDICARE PATIENT ACKNOWLEDGEMENT

  • ASSIGNMENT OF BENEFITS

  • I authorize payment of Medicare benefits directly to Dermatology Consultants of Sacramento for services provided to me. I authorize the release of medical information necessary to process Medicare claims and related insurance claims.

  • MEDICARE COVERAGE

  • I understand that Medicare does not cover all medical services. I am responsible for:

    • Annual deductibles

    • Coinsurance amounts

    • Services determined by Medicare to be non-covered or patient responsibility

  • SECONDARY INSURANCE

  • If I have supplemental or secondary insurance, the practice may submit claims as a courtesy when appropriate information is provided. I remain responsible for any balances not paid by Medicare or my secondary insurance carrier.

  • ADVANCED BENEFICIARY NOTICES (ABN)

  • For services that Medicare may not cover, I understand that I may be asked to sign an Advance Beneficiary Notice (ABN) before treatment.

    The ABN will explain:

    • Why Medicare may deny payment

    • Estimated costs

    • My options regarding treatment

  • Date of Signature
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: