herndondermatology.com - Registration Form

REGISTRATION INFORMATION
Date

MonthDayYear
Date
Referred by
Patient's Name

First NameLast Name
Responsible party (if a minor)
Relation to patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex

FemaleMale
Birth-date

MonthDayYear
Date
Marital status

Single MarriedWidowedSeparatedDivorced
Home Phone No.
Please enter a valid phone number.
Work Phone No.
Please enter a valid phone number.
Cell Phone
We would like to send you all appointment reminder via text
E-Mail
example@example.com
Occupation
Patient Employed by
Employment Address
Spouse's or Parent's Name
Occupation
Employed by
Employment Address
Has anyone in your family been seen in this office?
List their names

Insurance Information (Payments/Co-pay Required at Time of Service, Unless Prior Arrangements Have Been Made)

	Insurance Company Name	Policyholder	Date of birth	Policy Number
1
2

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical/medical benefits to Dr. Anh P. Dang-Vu, for the services rendered by her in person or under her supervision. I understand that I am financially responsible for any balance not covered by my insurance/ Medicare.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Dr. Anh P. Dang-Vu, to release any medical or incidental information that may be necessary for either medical care or in processing application for financial benefits.

RECEIPTS OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGMENT

I certify that I have received a copy of Dr. Anh P. Dang-Vu’s Notice of Privacy Practices.

A photocopy of these assignments shall be valid as the original.
Signature

Clear
Print Name
Parent's/Guardian Signature

Clear

INFORMATION REGARDING OUR PRACTICE

We currently participate with several insurance plans. Please check with our staff. For us to process your insurance claims properly we ask that you to provide us with adequate information. By signing the necessary forms during registration, we will be happy to file your claims for you.

If your insurance plan requires you to have a referral, it is the patient’s responsibility to obtain the referral not our doctor’s office. Be prepared to pay in full for your services if you arrive without a referral. It is also your responsibility to be informed as to what services your insurance plan will and will not cover. We cannot adjust charges or diagnosis codes after services have been provided. Co-pays are paid at the time of your visit. If your insurance company denies payment for your charges, your balance must be paid within 60 days. We do use a collection agency to assist in collecting unpaid balances. Any balances remaining after insurance has paid will be billed to you. There is a $25 returned check fee.

Because your insurance policy is an agreement between you and your carrier, disputes related to your coverage are to be handled by you and your insurance company.

We ask for 24-hour notice for cancellations. We will charge a $30 fee for appointments not kept and cancellations received the same day. Reminder calls are done only as courtesy.

Please provide our front office staff with accurate and up to date information. By doing so we can process your claims more efficiently. Most importantly, please fill out your patient information neatly. If we cannot read your hand-writing we cannot contact or accurately file your claims for reimbursement.

PATIENT FINANCIAL AGREEMENT

I hereby authorize ANH P. DANG-VU, MD, PC to apply for benefits on my behalf for services rendered. I certify that the information I have reported about my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim to my insurance company to determine these benefits payable. I request that payment of authorized benefits to be made to ANH P. DANG-VU, MD, PC on my behalf.
I further acknowledge and understand the following:
1. ANH P. DANG-VU, MD, PC participates with certain HMO/PPO programs. If I am covered by an HMO or PPO that the office participates with, I agree to pay my co-payment at the time of service.
2. Commercial insurance participants may be required to pay in full for charges at time of service. As a courtesy, ANH P. DANG-VU, MD, PC will submit insurance claims on my behalf requesting that payment be made directly to them. If the commercial insurance carrier agrees to pay the physician directly, I will be required to pay any deductible (if not met) or any applicable co-insurance amounts.
3. I understand that I am financially responsible for any non-covered and / or denied charges incurred on my behalf.
4. I understand that for my office consultations with ANH P. DANG-VU, MD, PC without a proper referral for the date of service, I will be held financially responsible for the office visit.
5. I understand that if I do not provide the office with the proper insurance information at the time of service, I will be held financially responsible for the visit.
6. A copy of this agreement may be used in place of the original.
Please sign below to indicate that you have read and understood the information above.
Patient/Parents/ Guardian Signature

Clear
Date

MonthDayYear
Date
WAIVER FOR PERMISSION TO REPORT LAB RESULTS

We would like to ensure that you are notified of your test results in a timely manner. To best accomplish that we ask that you complete the following question and we will do our best to accommodate them in our effort to assure smooth communication.
Would you prefer that we contact you with normal results?

YesNo
Phone number that you would like us to call with you results
Please enter a valid phone number.
Would you like us to leave the results on your answering machine?

YesNo
Is it OK to call you at work?

YesNo
Home telephone#
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Would you like us to leave a message with another person?

YesNo
If yes, with whom?
Patient/Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

PATIENT MEDICAL HISTORY
This form is a part of your permanent medical record. Please complete it as thoroughly as possible.
Name
Date of Birth

MonthDayYear
Date
Age
Date of Visit

MonthDayYear
Date
Reason for Visit
Skin check for skin cancer, abnormal moles today?

CompleteAbove the waistDecline
List of Medications
Allergies
Past and Current Medical History
Past Surgical History
Family History of non-melanoma or melanoma skin cancers
Should be Empty:

REGISTRATION INFORMATION

PATIENT MEDICAL HISTORY