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Patient Information
Last*
First*
MI*
Street*
City*
State*
Zip Code*
Home Phone:*
Format: (000) 000-0000.
Cell Phone:*
Format: (000) 000-0000.
Work Phone:
Email*

Confirmation Emailexample@example.com
Date of Birth*

MonthDayYear
Date
SSN
Identification Card/Driver's License (Please upload a picture of the FRONT of card)*

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MaleFemale
American IndianAsianBlackPacific IslanderDecline to AnswerOther
HispanicNon-HispanicDecline to Answer
EnglishSpanishOther
Emergency Contact
Full Name*
Home Phone*
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Employment Information
Employer*
Not EmployedFull-TimePart-TimeRetiredUnknown
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Extension
Insurance Information
YesNo
Primary Insurance
Name
Policy Holder
Policy Holder Date of Birth

MonthDayYear
Date
Relationship to Insured
Policy Number
Group Number
Secondary Insurance

Insurance Name: blanks
Policy Holder: blank
Policy Holder Date of Birth:   Date
Relationship to Insured:   Type a label
Policy Number:   Type a label
Group Number:   Type a label
Additional Insurance

Insurance Name:   Type a label
Policy Holder:   Type a label
Policy Holder Date of Birth:   Date
Relationship to Insured:    Type a label
Policy Number:   Type a label
Group Number:   Type a label
Insurance Card (Please upload a picture of the FRONT of card.)

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Insurance Card (Back of Card)

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Patient Medical History
Full Name*
Referred By*
Reason for visit*
Where (location) ?*
How Long ?*
NoneItchingStingingBurningPainfulWorseningImprovingUnchanging
Not NoticeableIntenseModerateMild
Present all the timeComes and goesRarely occurs
How has it been treated?*
Other skin condition(s):*
Topical (skin) medications already used: *
Weight LossWeight GainFeverChillsSudden Vision ChangesLoss of VisionSores in the Mouth or LipBlisters in the Mouth or on the LipsHearing LossPalpitationChest PainSevere CoughShortness of BreathNausea or VomitingChange in Bowel (Diarrhea/Constipation)Painful UrinationBlood in UrineMuscle StiffnessJoint PainMasses or Lumps on the SkinHair or Nail ChangesMemory ChangeLoss of Balance

Past Medical History / Inactive Problems:*

Rows	Yes	No
High Blood Pressure
Heart Disease
Cardiac Pacemaker
Heart Murmur
Diabetes
Liver Disease or Hepatitis
Anemia
HIV Infection
Seizures or Epilepsy
Radiation Therapy
Ultraviolet Light Treatment
Cancer
Stomach/Bowel Problem
Recent Weight Loss
Asthma or Lung Problems
History of Skin Cancer
Kidney/Bladder Problem

Surgical History
Do you have a pacemaker or defibrillator? Yes No*
If Yes, when? Date and which one?
Do you have an artificial heart valve or heart stent? Yes No*
If Yes, when? Date and which one?
Do you have artificial joint replacement(s)? Yes No*
If Yes, when? Date
Are you taking any anticoagulation medications? Yes No*
If Yes, which one?
Do you have mitral valve prolapse or endocarditis? Yes No*
If Yes, when Date and which one?
Do you have allergies to injected anesthetics? Yes No*
If Yes, which one(s)?
YesNo
Please list all your Current Medications:*
Please list any Medication Allergies:*
Please list any family members with History of Skin Cancers or other Skin-Related Diseases:*
Please list your occupation*
NoOccasionallyDaily
NeverSome DaysEverydayFormer (Quit)Unknown
PregnantBreastfeeding
PREFERRED PHARMACY
By my signature below, I confirm the above information regarding the medical history and review of systems are correct and up-to-date.
PATIENT SIGNATURE*

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Photography Permit
I hereby authorize the appropriate personnel of the office of Dr. Rick Lin, Dermatologist and/or Oasis Dermatology Group, PLLC. to take photographic and digital pictures of my skin condition.

I hereby state that it has been fully explained to me that said pictures are taken for the purpose of medical record documentation and for the showing to the duly licensed physicians, and authorized paramedical personnel, for teaching, research, and publication purposes.

I further state that at the time of the execution of the consent, that I am fully aware of the pictures to be taken and the uses, as described above. I also have had the opportunity to ask all questions with respect to the taking of the pictures and the use thereof which have been fully explained to me and to my complete satisfaction by personnel of Oasis Dermatology Group, PLLC.
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Patient Consent For Use and Disclosure of Protected Health Information
The following Individuals are authorized to receive my healthcare information regarding medical records, appointments and/or any other information Oasis Dermatology has in its medical records regarding treatment, diagnosis, labs or pathology reports.
Name
Relationship
Name
Relationship
Name
Relationship
In order to revoke my consent for the above individuals to receive my healthcare information; I must submit in writing my revocation of consent directly to Oasis Dermatology HIPAA Compliance Officer: Yvonna Molano.

Phone: (956) 971-0404
Email: oasisdermatologynurse@gmail.com
Signature*

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Patient Consent for Use and Disclosure of Protected Health Information
With my consent, Oasis Dermatology Group, PLLC., of McAllen, Texas, hereinafter referred to as "The Practice", or their office staff, may use and disclose PHI (Protected Health Information) about me to carry out TPO (Treatment, Payment and healthcare Operations Please refer to Oasis Dermatology Group, PLLC., of McAllen, Texas, Notice of Privacy Practices for a more complete description of such uses and disclosures which has been provided to you along with this form. I understand it is my right to review the Notices of Privacy Practices prior to signing this consent. Oasis Dermatology Group, PLLC., of McAllen, Texas, or their office staff, reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by visiting the practice and requesting a copy or by forwarding a written request to the Privacy Officer at 3100 Buddy Owens Blvd, McAllen, Texas 78504.

With my consent, The Practice may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out clinical care, including laboratory results among others.

With my consent, The Practice may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, and/or billing.

With my consent, The Practice may email to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that The Practice, 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 The Practice to use and disclose my PHI to carry out TPO. I also have been informed that I have the right to inspect and/or request copies of my child(ren) medical information and to receive an accounting of disclosures that have been made regarding Release of Medical Records/Information

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, The Practice may decline to provide treatment to me.

You may complain to us through our HIPAA Compliance Officer or to the Secretary of Health & Human Services through the U.S. Department of Health & Human Services Office for Civil Rights if you believe your privacy rights have been violated.

I consent to my medical information being disclosed and used for purposes as stated above.

I also acknowledge that I have been provided with a "Notice of Privacy Act" as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and had an opportunity to ask questions and acknowledge that I understand my rights as they pertain to HIPAA and the Texas Privacy Act.
Signature of Patient or Legal Guardian*

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Office Financial Policy
Welcome to the Dermatology Clinic of McAllen. In order for our medical staff to be able to deliver the quality of care that you are accustomed to, we have established our financial policies. The following is the list of guidelines that are necessary in order to continue to provide high quality care and make your visit as pleasant as possible.

PLEASE READ ALL INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW.

1. We ask that you present your insurance card at each visit. It is your responsibility to provide us with the correct information to bill your insurance.

2. If you have a change of address, telephone numbers, or employer, please notify the receptionist.

3. We will collect your deductible, co-payment, or charge for non-covered services at the time of your visit. If you have a balance after an insurance payment from a previous service, we will also ask for that payment. We accept cash, checks, Visa, MasterCard, Amex, and Discover.

4.If we do not participate with your insurance company, you will be expected to make payment in full at the time service is rendered.

5. If your insurance denies our charges or does not pay us in a timely manner, or if your account becomes delinquent, we reserve the right to refer your account to a collection agency and to be reported to one or more credit bureau(s).

6. MEDICARE PATIENTS: We are participating providers with Medicare and will bill Medicare for all of your covered charges. If you have Supplemental Insurance, we will also bill that for you. If payment is not received from your supplemental insurance within 45 days of being submitted, we will bill you for the balance due. If you do not have supplemental insurance, your portion (20% of the amount allowed by Medicare) will be collected at the time of service. Each year you will be expected to pay the allowed amount of your charges until your Medicare deductible is met.

7.HMO-PPO PATIENTS: If we participate with your plan, we will bill your insurance for you. Your co-payment will be collected at the time of service-NO EXCEPTIONS. If your plan requires you to choose a primary care physician (PCP), it is your responsibility to make sure your insurance company has the physician and/or physician assistant you are seeing as your PCP. If your plan requires you to have an authorization to see a specialist, you will need to obtain that from your PCP. Note that this office does not do retroactive billing or accept retroactive referrals. If we do not participate with your plan, we will verify your out-of-network benefits, and will expect payment of your portion of the charges at the time of service.

8.SELF-PAY PATIENTS: Patients with no Insurance will be expected to pay at the time of service. If you will not be able to pay in full; you must contact our billing department prior to seeing your physician and/or physician assistant to make payment arrangements.

9. Your insurance is a contract between you, your employer, and the Insurance company. We are not a party to that contract. It is very important that you understand the provisions of your policy. We cannot guarantee payment of all claims. If your insurance company pays only a portion of the bill or rejects your claim, any contract or explanation should be made to you, their policy holder. Reduction or rejection of your claim by your insurance does not relieve you of your financial obligation.

Remember, whether you do not have Insurance, you are ultimately financially responsible for payment of your charges. If you have any questions regarding our financial policy, please feel free to contact us.

I have read and have full understanding of the financial policy of Oasis Dermatology Group, PLLC.
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Patient Information

Emergency Contact

Employment Information

Insurance Information

Patient Medical History

Surgical History

Photography Permit

Patient Consent For Use and Disclosure of Protected Health Information

Patient Consent for Use and Disclosure of Protected Health Information

Office Financial Policy