Latest Pediatric Patient Form

PEDIATRIC PATIENT INTAKE FORM
PATIENT'S NAME:
DATE OF BIRTH:

MonthDayYear
Gender:

MF
ADDRESS:
CITY:
STATE:
ZIP CODE:
PARENT/GUARDIAN NAME:
EMAIL
HOME PHONE:
THIS IS MY PRIMARY NUMBER
CELL PHONE:
THIS IS MY PRIMARY NUMBER
PREFERRED LANGUAGE:
RACE:
INSURANCE INFORMATION
INSURANCE COMPANY:
ID#:
SUBSCRIBER NAME:
SUBSCRIBER DATE OF BIRTH:

MonthDayYear
Date
EMERGENCY CONTACT INFORMATION
NAME:
RELATIONSHIP:
TELEPHONE:
PATIENT'S NAME:
DOB:

MonthDayYear
PEDIATRICIAN:
TEL:
PHARMACY:
TEL:
PHARMACY ADDRESS:
REASON FOR TODAY'S VISIT:
HAS THE PATIENT HAD A FLU SHOT?

YESNO
PAST MEDICAL HISTORY: (Please CHECK all that apply or check NONE)

AnxietyArthritisAsthmaBone Marrow TransplantCongenital Heaert ProblemDepressionDiabetesGerdHepatitisHIV/AIDSThyroid ProblemLeukemiaLymphomaRadiation TreatmentSeizures
PAST SURGERIES

NONEOther
SKIN DISEASE HISTORY (Please check all that apply) **Must check “NONE” if none applies.

NONEAcneDry SkinAsthmaEczemaBasal Cell Skin CancerBlistering SunburnHayFever/AllergiesFlaky/itchy scalpPoison IvyPrecancerous MolesPsoriasisSquamous cell skin cancerOther
Does Patient wear sunscreen?

YESNO
If yes, what SPF
Do you tan in a tanning salon?

YESNO
Do you have a history of Melanoma?

YESNO
If YES, RELATIONSHIP?
SOCIAL HISTORY: (Please CHECK all that apply)
Cigarette Smoking:

Currently SmokesHas smoked in the pastNever smokedFormer Smoker
Alcohol Use:

EtOH-NoneEtOH-less than 1 drink a dayEtOH-1-2 drinks per dayEtOH-3 or more drinks per day
Patient's Name:
Date of Birth:

MonthDayYear
NO MEDICATIONS

No
MEDICATIONS: (Please list all medications including over the counter)
NO ALLERGIES

No
ALLERGIES: (Please list all allergies)
ALERTS: (Check all that apply)

NONEAllergy to adhesiveAllergy to lidocaine or other anestheticsAllergy to topical antibioticsArtificial heart valveDefibrillatorPremedication prior to proceduresMRSAPacemakerRapid heart beat with epinephrinePregnancy or planning pregnancy
GUARDIAN'S SIGNATURE

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Date

MonthDayYear
Date
Financial Policies & Payment

Your health coverage is a contract between you and your insurer, not the physician. Third party payers (commercial and government insurers) reimburse the physician according to a negotiated fee schedule. However, if issues arise, the patient is ultimately responsible for payment. As a courtesy to our patients, we will submit your claim to the insurer. You will then receive an EOB (explanation of benefits) in the mail/by email directly from your insurer detailing the amount you are required to pay, if any. We are now in the era of managed care. Insurance companies are concerned about the rising costs of healthcare. In an attempt to control their costs, they share the burden of paying for your healthcare with you. Please understand that we did not select your insurance plan. You will be responsible for any co-payments and/or deductibles or non-covered services specified by your insurer at the time of service. A deductible is the amount of money your insurance company requires you to pay before your plan “kicks in” and covers the rest. You should assume every procedure done in a dermatology office will be applied to your deductible. We reserve the right to collect deductibles and coinsurance up-front PRIOR to certain procedures. We are contractually obligated with your insurer to collect these charges. There are no exceptions. If your insurance requires a REFERRAL to see a specialist, it is your responsibility to ensure our office has that referral PRIOR to your visit. If we do not have a referral, your insurance will not cover the visit and you will be responsible for the cost of the visit. You will also be financially responsible if your health plan is not a plan our office participates in.

We accept payment in the form of cash, personal check, Visa, Mastercard, Discover, American Express, and CareCredit. There is a $25 returned check policy.

Patients with Out of Network Coverage

If we are not a provider with your insurance plan, you are expected to pay 100% of the charges at the time service is rendered. A claim form will be given at the end of the visit to submit to your insurance company.

Patients with No Insurance Coverage

Self pay patients are required to pay the office visit fee before seeing the physician. If procedures are deemed necessary, the patient will be responsible for these costs as well. We will discuss the estimated charges before the procedure is performed. For larger procedures, such as surgical removal of skin cancer, full payment is required the day the procedure is performed. An estimate of the cost will be provided prior to your surgery.

Pathology and Lab Fees

Diagnostic fees for skin biopsies or excisions are the patient’s responsibility. Facilities our practice uses include D-Path, DermPath, and Inform Diagnostics to name a few. If you have questions about a bill received from one of these entities, you should call the phone number listed on the statement. We do not have the authority to discuss charges or your account balance with these laboratories.

Financial & Collections Policy

As a courtesy, we will file an insurance claim to any carrier we participate in for our services. In order to properly file or appeal a claim, we must have each patients’ current valid insurance card. We will ask for this item when scheduling your first appointment. This ensures we have the most pertinent information on file and we can verify insurance eligibility prior to or on the date of service, thus helping make your visit more efficient.

In order to continue to provide outstanding medical care, we make every effort to collect money owed to our practice for previous treatment. All patient balances are due 30 days from receipt of the statement from our office, or at any follow up visits. If, after several attempts, we fail to collect the outstanding balance, you may be unable to schedule future appointments until that balance is paid in full.
Patient/Guardian Signature

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Date

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Date
PRINT PATIENT'S NAME OR LEGAL GUARDIAN NAME
DATE

MonthDayYear
Date
SIGNATURE OF PATIENT OR LEGAL GUARDIAN

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INSURANCE PARTICIPATION
I,
Patient's Name
have checked with my insurance and
Check one of the following:*

is in network with Poblete Dermatology.is NOT in network with Poblete Dermatology and I understand the financial responsibilities.
Check one of the following:*

that I DO NOT need insuance referralsthat I DO need insurance referrals and have contacted my PCP to obtain the insurance referral.
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Signature of Patient
MonthDayYear
Date
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We are required by State and Federal laws, including the HIPAA rules, to safeguard general health related information about you. We have a Notice of Privacy Practices that explains how your protected health information is handled and how we may use and/or disclose your protected health information. The Notice of Privacy Practices is provided to patients (and /or their authorized representatives) when they first become our patient and a copy of its available on our website: www.pobletedermatology.com.

We are asking you to sign this form to show that we offered you a copy of our Notice of Privacy Practices. Personal copies can be requested from our staff. By signing below, you are only acknowledging that you were offered or received a copy of the Notice of Privacy Practices. You may refuse to sign this acknowledgement if you wish. You are not making any statements about the content of the Notice of Privacy Practices and about your agreement or disagreement with any portion of it.

Acknowledgement

I acknowledge that Poblete Dermatology LLC has offered or provided me with a copy of its Notice of Privacy Practices, which describes how medical information about me may be used and/or disclosed, and how I can access this information. I understand if I have any questions or complaints I may contact: Privacy Officer Claudia VanSaders RN, or DR. Maria Abello-Poblete, at 609-838-9040. I also understand that I am entitled to receive updates if Poblete Dermatology LLC amends or changes its Notice of Privacy Practices in a material way.
Signature of patient/Patient's representative

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Printed name of patient/Patient's representative
Date

MonthDayYear
Date
1601 Whitehorse-Mercerville Road, Suite 2, Hamilton NJ 08619. 609-838-9040 support@pobletedermatology.com
NO SHOW/CANCELLATION POLICY

We understand that there are times when you must miss an appointment due emergencies or work and family obligations. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit due to a seemingly “full” appointment schedule. As of March 1, 2019, our policy has been changed & will be valid for 1 year from the last appointment date
- Appointment Policy
  
  ○ 24 hour notice is needed to cancel/change an appointment. If 24 hour notice is not given, the following will apply:
■ Appointments for examinations, consultations, evaluations, and checkups will incur a $25 fee.

■ Appointments for surgical procedures will incur a $50 fee due to the large block of time set aside for the procedure.

■ Appointments for cosmetic procedures will incur a $100 fee due to the block of time and ordering of specific materials.

○ No Show appointments. If you fail to show for a scheduled appointment, you will be considered a “no show”. No shows are subject to the fees described above.

○ 8-8:30am and 4:30-5:30pm appointments. Due to the high demand for these time slots, the following will apply:

■ Once scheduled for your appointment, if you fail to show for the appointment without notification, you may not be able to schedule another appointment for those time slots.

Any fees are charged to the patient and are NOT covered by insurance. Any fees are due at the time of the patient’s next office visit.

By signing this form, the patient acknowledges that they have been informed of, and consent to the Poblete Dermatology, LLC cancellation policy.
Print Patient Name
Date

MonthDayYear
Date
Patient/Guardian Signature

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INSURANCE PARTICIPATION