SPECTRUM DERMATOLOGY NEW PATIENT DEMOGRAPHICS

Patient Name

First NameLast Name
Date of Birth
MM/DD/YYYY
AUTHORIZATION TO RELEASE INFORMATION VIA PHONE

I hereby authorize confidential communications from the physicians or staff of Spectrum Dermatology/The Physicians' Group (TPG) regarding my health, care, treatments, appointments, prescriptions, results, etc...to be received at any of the numbers given below. I authorize the staff to leave messages on the voicemail or with the individual who answers the phone at any of the below numbers:
Home Phone
Work Phone
Cell Phone*
Other
I authorize the following individuals to call the office on my behalf or be called from the office to verify the status of appointments, treatment plans, medications and account information. These individuals may also pick up prescriptions and/or samples that I have requested:
Name
First & Last Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Name
First & Last Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Name
First & Last Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Name
First & Last Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
CONSENT FOR NON-PARENT/GUARDIAN TO BRING MINOR CHILD TO APPOINTMENT

I authorize the following individuals, who is a person over 18 years of age, to bring the minor child to his or her appointment, and to consent to medical care which is deemed necessary by the physicians and medical providers at Spectrum Dermatology at the time of the appointment. I understand that this delegation includes receiving health information about the minor necessary to make immediately necessary health care decisions:
Name
First & Last Name
Relationship to Patient
e.g. Maternal aunt, paternal grandmother, family friend
Name
First & Last Name
Relationship to Patient
e.g. Maternal aunt, paternal grandmother, family friend
Name
First & Last Name
Relationship to Patient
e.g. Maternal aunt, paternal grandmother, family friend
Name
First & Last Name
Relationship to Patient
e.g. Maternal aunt, paternal grandmother, family friend
I understand that I must call the clinic beforehand and send a hand written letter with the patient if a different individual that is not listed on this page must bring the minor child to his or her appointment.

This consent is valid until revoked in writing by me, the parent or legal guardian.
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Date

AUTHORIZATION FOR TREATMENT
I hereby authorize the physician(s) in charge of the care of the patient of Spectrum Dermatology/ The Physicians' Group (TPG) to administer treatment as may be deemed necessary or advisable in the diagnosis and treatment of this patient.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I hereby authorize the physician(s) of Spectrum Dermatology/TPG to disclose any or all of the information in the medical records to any person, corporation or agency which is or may be liable for all or part of Oklahoma Sports Science & Orthopedics charge or who may be responsible for determining the necessity, appropriateness, amount of other matter to the physician's treatment or charge including, but not limited to, insurance companies, health maintenance organizations, preferred provider organizations, workers' compensation carriers, welfare funds, the Social Security Administration or its intermediaries or carriers. I UNDERSTAND THAT MY MEDICAL RECORDS MAY CONTAIN INFORMATION THAT INDICATES THAT I HAVE A COMMUNICABLE DISEASE WHICH MAY INCLUDE BUT NOT LIMITED TO DISEASES SUCH AS HEPATITIS, SYPHILIS, GONORREA OR THE HUMAN IMMUNODEFICIENCY VIRUS, ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROM (AIDS). I give my consent to the release of all information in my medical records including any information concerning identity, and release Spectrum Dermatology/TPG, its agents and its employees from liability in connection with the release of the informatoin containe therein.
ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize payment directly to my physician(s) of the medical insurance benefits otherwise payable to me for services rendered during my visit at Spectrum Dermatology/TPG. I understand I am financially responsible for charges not covered by this assignment.

You agree that, to the fullest extent permitted by law, we may remit all or a portion of any credit balances or other amounts due to you from us to any of our affiliates to whom you have any balance owing fees, items or services. We will advise you to make any payments we make on your behalf to our affiliates.
WAIVER OF RESPONSIBILITY OF VALUABLES

I hereby release Spectrum Dermatology/TPG from any claim for responsibility or damages in the event of my property, including money and jewelry.

I understand a photocopy of this document is as valid as the original.
NOTICE TO PATIENTS: Information in your medical record that you have/may have a communicable or venereal disease is made confidential by law and cannot be released without your permission, except in limited circumstances, including release of persons who have had risk exposures, release pursuant to an order of the court of the Dept. of Health, release among the healthcare providers of release for statistical or epidemiological purposes. When such information is released, it cannot contain information from which you could be identified unless release of that identifying information is authorized by you, by an order of the court, or the Dept. of Health, or by law.
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Date

FINANCIAL POLICY
Thank you for choosing Spectrum Dermatology/The Physicians' Group (TPG) as your healthcare provider. At The Physicians' Group, we are dedicated to providing the highest quality, most cost effective care.

In addition to accepting traditional insurance plans and Medicare, we are contracted with numerous Preferred Provider Organizations (PPO) and Health Maintenance Organizations (HMO). Because each plan is different, and constantly updating providers' participation status, please check with your particular plan to make sure we are currently participating in your network. We ask that you assist us in maximizing your insurance coverage by cooperating fully in all referral, prior authorization and pre-certification processes. Please be aware that all insurance carriers do not consider some services rendered a covered benefit. It is important that you are aware of your insurance policy provisions of coverage.

Accurate, up-to-date information is the patient's responsibility; please notify our office of any changes in your insurance or personal billing information. Please bring your current insurance card, or any other information that is required by your insurance company to each appointment. By maintaining updated information this ensures that your medical claims are filed correctly and prevents any unnecessary delays in processing your claim.

Payment for all co-insurance, deductible and non-covered services are due at the time of service unless special payment arrangements have been made. Payments can be made by cash, check, money order, Visa, Discover, American Express or MasterCard. We do have a payment plan for patients who have financial concerns. Please notify our office at 405.285.8823 to inquiry about financial arrangements.

There is a $35 charge for any FMLA, disability or accidental forms completed. This charge is applicable per form completed and is payable prior to completion.

Again, thank you for allowing The Physicians' Group to participate in your care.

Sincerely,

The Physicians' Group & Spectrum Dermatology Staff

My signature below acknowledges receipt of this Financial Policy:
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Date

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have been provided with the Notice of Privacy Practices ("Notice"),

*The Notice of Privacy Practices Pamphlet can be requested at the front desk*:
- The Notice tells me how Spectrum Dermatology/The Physicians' Group LLC or HPI Physicians, LLC, as applicable (the "Practice"), will use protected health information for the purposes of treatment and healthcare operations.
- The Notice explains in more detail how Spectrum Dermatology may use and share protected health information other than treatment, payment and healthcare operations.
- Spectrum Dermatology will also use and share protected health information as permitted or required by law.
- If I am a patient receiving health services at Spectrum Dermatology, I consent to allowing them to use and disclose my protected health information contained in my treatment records maintained by Spectrum Dermatology for the purposes detailed in the Practices' Notice of Privacy Practices.
This form must be signed by either the patient or by the patient's personal representative.

Current contact information for patient or personal representative/guardian signing this form:
Name (print)*
First & Last Name
Address*
Please list full address
Telephone*
E mail
example@example.com
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Date

PRACTICE POLICIES
To ensure all patients have the best experience and quality care, our clinic has implemented a cancellation, no show, and late policy.

NEW PATIENTS
- All new patients are required to check-in 15-30 minutes prior to appointment time with paperwork completed entirely.
- Paperwork must be filled out prior to appointment time. Paperwork may be completed in office if patient is checked in a minimum of 30 minutes prior to appointment.
- Patient may be asked to reschedule if paperwork is not completed by the appointment time.
CANCELLATION
- Please notify our office 24-hours prior to your appointment for cancellations or to reschedule so that we have an opportunity to use the appointed time to provide treatments to others.
- Monday appointments must be cancelled or rescheduled no later than the Friday prior to the appointment.
- Rescheduled appointments will be scheduled at the earliest availability.
ARRIVAL

We recognize that the most punctual individuals sometimes run late. If your appointment time is missed, due to late check-in, your appointment may have to be rescheduled.

NO SHOW
- Three No Show appointments in a calendar year, may result in dismissal of care. If a new patient appointment is No Showed, the patient potentially may not be rescheduled.
- No Show appointments are subject to a $25 charge to the patient, not payable by insurance. Charges must be paid prior to scheduling the next appointment.
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Date

ONCE YOU PRESS SUBMIT YOU WILL BE REDIRECTED TO SPECTRUM DERMATOLOGY'S PATIENT PORTAL TO COMPLETE THE MEDICAL HISTORY PORTION.
Please reference the email you received the day you scheduled the appointment with your log-in credentials. Please be aware that the log-in credentials given will only be good for 72 hours after receipt of the email.

*If you scheduled your appointment before we launched this new patient paperwork process, 05/10/2023, please contact our office at 405-285-8823 to request patient portal access. If you cannot access the portal prior to your appointment time, please arrive 15 minutes early to give yourself adequate time to complete the medical history portion.*

The username should be the patient's first and last name and last 2 digits of their birth year. e.g. JohnSmith22

Please use whichever password you created.

If you are locked out or have any questions regarding this, please contact our office during normal business hours at: 405-285-8823

Once you are logged in successfully, please proceed to the "My Health" tab at the top of the page and complete the following fields:
- Insurance and Pharmacy
- Medications - Please list any topical medications and include if it's an ointment, cream, spray, etc. as well as the strength. (i.e. hydrocortisone 2.5% ointment)
- Allergies
- Past medical history
- Skin Disease History
- Quality Measures
- Implantable devices
- Family History
Thank you! We look forward to having you as our patient!

Spectrum Dermatology Staff
Should be Empty:

PATIENT INFORMATION

INSURANCE INFORMATION - In order to file a claim, we will need a copy of your insurance card upon check-in. *Please specify if you are "Self-Pay"

PATIENT EMPLOYMENT INFORMATION

IF THE PATIENT IS UNDER 18, PLEASE LIST EACH PARENT'S NAME, DOB, PHONE NUMBER & RELATION (e.g. parent, step-parent, etc. )

EMERGENCY CONTACT

AUTHORIZATION FOR TREATMENT

FINANCIAL POLICY

Acknowledgement of Receipt of Notice of Privacy Practices

PRACTICE POLICIES

ONCE YOU PRESS SUBMIT YOU WILL BE REDIRECTED TO SPECTRUM DERMATOLOGY'S PATIENT PORTAL TO COMPLETE THE MEDICAL HISTORY PORTION.