Quality Dermatology New Patient Form

QUALITY DERMATOLOGYRENATA FLAKS, DNP707 MAIN STREETTOMS RIVER, NJ 08753TEL: 732.244.2666FAX: 732.286.7040
UPDATED POLICY FOR NEW AND EXISTING PATIENTS
NO-SHOW / CANCELLATION / RESCHEDULING POLICY
To ensure appointment availability for all patients, patients are limited to two (2) rescheduled appointments per year.

At least 24 hours' notice is required to cancel or reschedule an appointment. Cancellations or rescheduling with less than 24 hours' notice, as well as no-shows, will result in a $50 fee.

Repeated cancellations or rescheduling may affect the ability to schedule future appointments.
Patient Name:

First NameLast Name
Patient Signature:
Date:

MonthDayYear

Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for Renata Flaks, DNP to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations {TPO}. (Renata Flaks, DNP's Notice of Privacy Practices provides a more complete description of such uses and disclosures)

I have the right to review the Notice of Privacy Practices prior to signing this consent. The practice reserves the right to revise its Notice of Privacy Practices at Renata Flaks, DNPs anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Renata Flaks, DNP. Privacy Officer at

Renata Flaks, DNP 707 Main Street
Toms River, NJ
08753

With this consent, Renata Flaks, DNP may call my home, cell or other phone number listed on my chart and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything pertaining to my medical care, including laboratory test results among others.

With this consent, Renata Flaks, DNP may mail to my home or other alternative locations Listed on my chart any item that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With this consent, Renata Flaks, DNP may e-mail me any items assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Renata Flaks, DNP restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Renata Flaks, DNP's use and disclosure of my PHI to carry out my TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent If I do not sign this consent, or later revoke it, Renata Flaks, DNP may decline to provide treatment to me.
Signature of Patient or Legal Guardian
Print Name of Patient or Legal Guardian

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Quality Dermatology, LLC
Renata Flaks, DNP
707 Main Street
Toms River, NJ 08753
(732) 244-2666
Patient or POA:

First NameLast Name
Please be advised, although your insurance company has authorized services, this is not a guarantee of payment. If your insurance company denies those services, you will be responsible for payment. (Please initial)
I have been advised that if Quality Dermatology does not accept my secondary insurance, I will be responsible for any remaining balance after my primary insurance. (Please initial)
It is my responsibility to obtain a referral if it is required by my insurance. If I fail to provide a valid referral at the time of service and my insurance denies my bills for lacking referral/authorization, I will be responsible for payment in full to Quality Dermatology. (Please initial)
I have been advised that Quality Dermatology sends all specimens to labs of practice choice. If patient's insurance is associated with specific lab(s), it is patient's responsibility to inform Quality Dermatology of their lab(s) before the appointment. (Please initial)
Patient or POA Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Dr. Renata Flaks, DNPQuality Dermatology707 Main Street, Toms River, New Jersey 08753Tel: (732) 244-2666Fax: (732) 286-7040
NON-COVERED, MEDICALLY UNNECESSARY SERVICES
Insurance, or Medicare, will not pay for services that are being performed for cosmetic purposes. The removal of benign lesions that are not inflamed or suspected of being dangerous falls into this category. These include:

Benign moles
Seborrheic keratosis that are non-irritated
Brown spots
Skin tags
Milium
Comedone extraction and blackhead removal
Hemangiomas
Other:
Fee:
This is an elective procedure for cosmetic purposes, and is therefore non-reimbursable by insurance, or under Medicare.

Payment for the above procedure or procedures is required at the time of service. Our regular fees will be used for the services.

I understand and agree with the above.
Print name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

CONSENT TO TREAT MINORS
By law, any child under the age of 18 years old cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf. You may appoint anyone who is over the age of 18 years of age to be responsible for your child when you are unable to accompany them to their medical appointment.
PARENT / LEGAL GUARDIAN
You must be present at your child's initial visit with the completed parental consent below
MINOR INFORMATION
Patient Name:

First NameLast Name
Patient Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PARENT / LEGAL GUARDIAN INFORMATION
Name:

First NameLast Name
Last four digits of SSN#:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Phone:
Format: (000) 000-0000.
Relationship to Patient:
Cell Phone:
Format: (000) 000-0000.
If you are not the parent, you will need to provide legal documentation that you are the legal guardian. This information will be kept in the patient's file
SPECIAL PERMISSIONS
This agreement is required in order for the minor child to be seen and treated without the parent/legal guardian present.
_____(Initials) ACCOMPANIED BY OTHERS: If I am unable to accompany my child to the appointment, the below listed individuals have my permission to accompany my child and make medical decisions regarding my child.
OTHER INDIVIDUALS ALLOWED TO ACCOMPANY MINOR:
Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient:
Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient:
CONSENT TO TREAT MINOR
- I authorize QUALITY DERMATOLOGY to treat and provide any healthcare services to my child deemed necessary for treatment and/or diagnosis.
- I also understand that, in the course of that treatment, photographs may be taken for clinical or educational purposes.
- I acknowledge that this consent will remain in effect until I revoke it in writing and present this document to the office or the minor reaches the age of 18 years.
By signing below, I certify that I have read the above information and have had any questions answered. My signature also certifies my understanding and agreement with the above information.
Parent / Legal Guardian Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Quality Dermatology

SMOKING HISTORY

QUALITY DERMATOLOGYRENATA FLAKS, DNP707 MAIN STREETTOMS RIVER, NJ 08753TEL: 732.244.2666FAX: 732.286.7040

UPDATED POLICY FOR NEW AND EXISTING PATIENTS

NO-SHOW / CANCELLATION / RESCHEDULING POLICY

Patient Consent for Use and Disclosure of Protected Health Information

Quality Dermatology, LLC

Dr. Renata Flaks, DNPQuality Dermatology707 Main Street, Toms River, New Jersey 08753Tel: (732) 244-2666Fax: (732) 286-7040

NON-COVERED, MEDICALLY UNNECESSARY SERVICES

QUALITY MEASUREMENTS For patients 65 and older

CONSENT TO TREAT MINORS

PARENT / LEGAL GUARDIAN

MINOR INFORMATION

PARENT / LEGAL GUARDIAN INFORMATION

SPECIAL PERMISSIONS

CONSENT TO TREAT MINOR