www.drvitulli.com - Patient Demographics Form

New Patient Demographics Form
Today’s Date*

MonthDayYear
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Sex*
Marital Status
If married, spouses’ name*
Phone Numbers
Cell Phone Number*
Work Phone Number
Email Address
example@example.com
Race
Ethnicity
Language Spoken
Employer
Occupation
Do you work indoors / outdoors?
Social Security Number
Primary Care Physician
Primary Care Physician’s Phone Number
Please enter a valid phone number.
If minor, name of parent or guardian
Insurance Information
Primary insurance
ID Number
Group Number
Policy Holder
Relationship
Date of birth

MonthDayYear
Do you have Secondary insurance*

YesNo
ID Number
Group Number
Policy Holder
Relationship
Date of birth

MonthDayYear
Emergency Contact
Emergency contact name*
Phone Number*
Please enter a valid phone number.
How did you hear about us?
Whom may we thank for your referral to our office?
Assignment of Benefits

Please, initial each line item and sign below
Records Release: I authorize the release of my health information by the Practice for the purposes of my current treatment, including the release of information to my referring or primary care provider and other health care providers participating in my current treatment, or as otherwise necessary for the Practice to provide treatment to me. I authorize the release of medical information (including billing information) as necessary for payment purposes to my insurance company, and any other person or entity responsible for payment for my medical treatment. I authorize the release of my health information to business associates of the Practice as necessary for the purposes of the Practice’s health care operations. *
(initial)
Assignment of Benefits: I authorize payments of medical benefits to the Practice and its providers for services rendered to myself and/or my dependents*
(initial)
For Medicare Recipients Only
Medicare Authorization: I request that payments of authorized Medicare benefits be made on my behalf to the Practice for any services furnished to me by its providers. I authorize any holder of my medical information to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original.
(initial)
MEDIGAP: I request that payments of authorized MEDIGAP benefits be made on my behalf to the Practice for any services furnished to me by its providers. I authorize any holder of my medical information to release to the MEDIGAP carriers any information needed to determine these benefits payable for related services. I understand I may refuse to sign this authorization and realize this may result in a delay of treatment and/or have potentially adverse health consequences. I understand I may change or revoke this authorization at any time.
(initial)
I certify that I have read and fully understand the procedural office policies of A Center For Dermatology, Cosmetic and Laser Surgery, including its Financial policy, and I agree to be bound by its terms.
Patient’s Name *

First NameLast Name
Patient’s Date of Birth*

MonthDayYear
Patient/Responsible Party Signature*

Clear
Date*

MonthDayYear

Privacy Protection
The Health Insurance Portability and Accountability Act (HIPAA) requires A Center For Dermatology, Cosmetic and Laser Surgery (Practice) to obtain your authorization to allow communications regarding your protected health information. This authorization gives permission to our staff to discuss your health care with a family member or any other individual that you may designate. It also allows us to leave recorded messages at your home, work, or on your cell phone related to your medical care and treatment, payment, appointment status, or follow-up. Please, list phone number(s) in order of preference for receiving appointment reminders and/or patient care calls:
Please, select type*

Home Phone NumberCell Phone NumberWork Phone NumberOther
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
Other Phone Number*
Please enter a valid phone number.
Please, select messaging preferences below*

No MessageMessage to callDetailed message
Please, check an applicable option below
I give permission to the Practice to contact me via e-mail with news announcements, events, and promotions.I choose to opt out of e-mail announcements
Email*
example@example.com
This authorization allows A Center For Dermatology, Cosmetic and Laser Surgery to discuss all aspects of my protected health information with the individuals listed below: *
The Notice of Privacy Practices is available for your review at the office. Please, ask our staff if you wish to obtain a copy for your records.
Patient’s Name *

First NameLast Name
Patient’s Date of Birth*

MonthDayYear
Patient/Responsible Party Signature*

Clear
Date*

MonthDayYear

Financial and Procedural Policies
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
We would like to take this opportunity to welcome you to our practice and thank you for choosing A Center For Dermatology, Cosmetic, and Laser Surgery for your skincare needs. An individualized comprehensive approach to skin wellness is the center of our philosophy and the focus of our care, as we believe that your skin’s health plays a major role in your overall wellbeing.

As we begin our commitment to serving you, we kindly request you carefully review and sign our financial and procedural policies agreement to acknowledge your responsibilities in relation to your medical care. Mutual adherence to this agreement is of crucial importance to our professional relationship and your overall experience with our office and staff. Please, feel free to ask any questions regarding the information contained in this document. You may retain a signed copy for your records.

Registration You are required to follow all registration procedures, which include providing, verifying, and/or updating personal information, presenting a valid government-issued ID, proof of current health insurance, and allowing A Center For Dermatology to take photographs for your medical record.

Medical Insurance and Payment for Services You are responsible for knowing your insurance policy and its coverage guidelines. Your medical insurance policy is a contract between you and your insurance carrier, which outlines your benefits and stipulates your share of financial obligations for your medical care under this contract: co-payments, co-insurance, deductible, out-of-pocket maximums. If you forfeit this obligation, your insurance company reserves the right to deny your coverage and leave you responsible for the entire cost of services. This contract also binds every medical service provider, participating with your insurance plan, to collect any applicable co-pays/co-insurance/deductible amounts for services rendered to you. Waiving these fees violates your contract and may result in the denial of your coverage.

CO-PAYMENT: a fixed amount you pay for routine office visits defined by your plan. It is usually a flat fee, paid per visit, regardless of the total amount of charges incurred.

DEDUCTIBLE: An annual amount to be paid by a patient for his/her medical care before any payments are made by the insurance carrier. Once the deductible is “met” (paid in full), an insurance carrier will begin covering its portion of the allowable amount of the charges.

Generally, insurance plans classify dermatological procedures as “surgery”; therefore, many insurance plans apply in-office procedures and treatments to deductibles.

If your plan has a deductible, some or all of the charges may be your responsibility.

CO-INSURANCE: a set ratio of the cost-sharing for your medical care between you and your insurance carrier.

OUT-OF-POCKET MAXIMUM: a maximum amount you pay out of pocket before your insurance carrier can provide a 100% coverage for your medical care. In general, out-of-pocket maximum is comprised of deductible amounts, co-pays and co-insurance.
Depending on your plan, your medical care coverage may be structured to include one or all of the above.

If you have provided us with insurance information, you are obligated to pay all co-payments, deductibles, and any non-covered out-of-network/reduced benefits at the time services are rendered. You may subsequently be invoiced for any additional amounts which are not paid by your Insurer. You have an affirmative duty to make sure that payment and/or correct information for payment is given to the Practice for reimbursement of services provided.
CO-PAYMENTS/CO-INSURANCE/ANY APPLICABLE UNMET DEDUCTIBLE AMOUNTS, AND OUTSTANDING ACCOUNT BALANCES ARE DUE AT THE TIME OF SERVICES.
- We verify your benefits in real-time, and your financial responsibility will be estimated upon the extent of your visit and treatments performed. Our staff can provide an estimate for scheduled treatments upon request.
- If we do not participate in your insurance carrier’s network, you will be billed self-pay rates. It is ultimately your responsibility to verify your medical care provider’s participation with your plan. Each insurance company has multiple plans: your provider may participate with the insurance company, but not your particular plan.
- Self-pay patients are required to remit payments in full at the time of services.
- Cosmetic treatments are not covered by insurance, and payments are due in full at the time of services.
- For your convenience, we accept the following forms of payment: cash, personal check, health savings cards, all major credit/debit cards, and Care Credit.
- Personal checks that are returned for non-sufficient funds are subject to an administrative fee of $50 in addition to the full amount of the check.
Account Credits and Refunds If you have a credit of $25 or less once your insurance claim has been processed, it will remain on your account to be applied towards your future visits, unless a refund is requested. We will issue a refund for a credit amount over $25 unless instructed otherwise by you. Refunds are executed via check, which will be mailed to you.

Delinquent Accounts Should temporary financial hardship affect a timely payment on your account, we encourage you to contact our office to arrange a payment plan. If your account becomes delinquent (over 90 days) and you have not established or met payment options with our billing office, your account may be turned over to a collection agency and reported to the Credit Bureau.

Accounts that have billing statements returned with no forwarding address will be charged $30 and turned over to a collection agency.

Pathology Charges Pathology services may be ordered to properly diagnose certain skin lesions/growths or disorders. In most cases, pathology services involve preparation and microscopic examination of biopsied skin samples by a licensed physician – pathologist – in a laboratory setting to obtain a diagnostic information. The work associated with processing biopsied tissue is a distinct, independent service billed for by the lab or physician rendering it. We are not a party to laboratory billing. For any questions regarding your billing statement for pathology services, please, contact the billing entity in charge, listed on your statement.

Appointment Cancellation/Missed Appointments -
Please help us to serve you better by keeping your scheduled appointments and following our cancellation policy. We require at least 24-hour notice when cancelling or rescheduling your appointment. It will allow us to attend to other patients who may be in need of an urgent treatment/care or accommodate patients on the waiting list. Late cancellations and missed appointments may be preventing another patient from receiving much-needed care. A fee of $50 will be charged to your account after 3 missed appointments or untimely cancellations. It must be paid before any future appointments can be made. We reserve the right to terminate physician-patient relationship and discharge patients from our practice for failure to adhere to our appointment cancellation policy.

Minor Patients Patients under the age of 18 must be accompanied by a parent or a legal guardian, responsible for treatment consents and payments. Unaccompanied minors will not be treated. If a parent or a legal guardian is not available to be present at the appointment, we require a notarized Medical Power of Attorney (POA), naming an authorized adult and listing permissions given to that adult.

We are not able to verify financial arrangements between divorced parents – the authorized adult accompanying the minor will be held responsible to remit all the payments due at the time of services.

Medications Refills are issued during regular office hours. Please, have the following information available when calling to request a refill: patient’s name, DOB, phone number, medication, dosage and strength, designated pharmacy, its address, and phone number.
Please, allow 48 business hours to have your refills issued. We do not call in prescriptions after business hours, weekends or holidays.
Plan ahead: contact our office three days before your medication is due to run out; if you are using a mail-order pharmacy, request a refill fourteen days in advance.

Some medications require prior authorizations from your insurance carrier. Please, anticipate a 7-10 - day approval process.
Any refill request requires a review of your medical records. Please, keep your follow-up appointments. It is our office policy to deny a refill if you have missed recommended follow-up visits. Follow-up evaluations are necessary to verify medications efficacy.
Medications prescribed by other physicians will not be refilled.

Medical Records Requests Records requests are fulfilled upon the receipt of a written PHI release authorization, signed by the patient or his/her legal representative. You may request a hard copy of this form at our office or download it on our website at www.drvitulli.com. Personal records requests may take up to 14 business days to be processed. Requests extended by insurance carriers or attorneys on your behalf may be subject to fees.
I certify that I have read and fully understand the procedural office policies of the Practice, including its Financial policy, and I agree to be bound by their terms.
Patient’s Name (please, print) *

First NameLast Name
Patient’s Date of Birth

MonthDayYear
Patient/Responsible Party Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Demographics Form

Phone Numbers

Insurance Information

Emergency Contact

Assignment of Benefits

For Medicare Recipients Only

Privacy Protection

Please, check an applicable option below

Financial and Procedural Policies

CO-PAYMENTS/CO-INSURANCE/ANY APPLICABLE UNMET DEDUCTIBLE AMOUNTS, AND OUTSTANDING ACCOUNT BALANCES ARE DUE AT THE TIME OF SERVICES.

I certify that I have read and fully understand the procedural office policies of the Practice, including its Financial policy, and I agree to be bound by their terms.