Greenwood Dermatology_Online Patient Forms

Which doctor are you seeing?

When is your appointment?

Date

Time

Hour Minutes

AM/PM Option

Today's Date*

Date

Last Name*

First Name*

MI

Date of Birth*

Date

Age*

Sex*

MaleFemale

Soc Security

State*

City*

Zip Code*

Home Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

To confirm return appointments, may we email or text you?*

YesNo

Email

example@example.com

With my consent Greenwood Dermatology may text, call, leave a message or mail to my home any items that assist the practice in carrying out treatment payment, and healthcare operations.

Greenwood Dermatology may text or leave a message with any medical information on my voicemail*

YesNo

Signature*

Place of employment

Place of employment Phone Number

Please enter a valid phone number.

Spouses place of employment

Spouses place of employment Phone Number

Please enter a valid phone number.

In case of Emergency who should be notified*

In case of emergency Phone Number*

Please enter a valid phone number.

Relationship to patient*

Parent, Spouse or Responsible Party (if different from patient)

Last Name

First Name

MI

Date of Birth

Date

Address

City

State

Zip Code

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Family Physician

Address

Were you referred by a physician

If yes who is the referring physician

Address or phone number of referring physician

Primary Insurance Carrier*

Policy holders Name*

Policy holders SSN

Policy holders Birthdate*

Date

Relationship to Patient*

Preferred Pharmacy*

Phone Number*

Please enter a valid phone number.

Specialty Pharmacy

Phone Number

Please enter a valid phone number.

Secondary Insurance Carrier

Policy holders Name

Policy holders SSN

Policy holders Birthdate

Date

Relationship to Patient

Please sign so we may have your insurance authorization on file I authorize any holder of medical and/or other information about me to be released to the above insurance company(s), and any information needed for this or a related insurance claim. I hereby assign to the physician all payments for medical services rendered to my dependents or myself. I understand that I will be billed and I am responsible for any amount that is not covered by my insurance.

Date*

Date

Signature*

Please present your insurance card(s) and a photo ID to the receptionist.

Payment Policy: The doctor appreciates the confidence you have shown in choosing us to provide for your healthcare needs. The service you have elected to participate in implies a financial responsibility on your part. As a courtesy, we will bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill. The patient or legal guardian is responsible for all fees incurred for office medical services regardless of insurance coverage. This includes any amount the insurance does not cover for office visits and in the unlikely event of complications from treatment, the patient is responsible for fees charged by other physicians or hospitals. Any amount that insurance does not pay will be billed directly to you. Any co-payments that you are liable for with your policy, as well as any medications, charges for noncovered services, products you may purchase at the office, and cosmetic services are due at the time of the visit.

Electronic recording is prohibited within the office. The Adult/Guardian who brings in the child will be responsible for all copayments and deductibles. We do not forward bills to other parties regardless of court rulings or divorce decrees. If we receive payment from the primary insurance, we will file a claim with your secondary. If we do not receive payment from your primary carrier, you will be billed for the entire amount. It is ultimately the patient's responsibility to verify that the physician is in your network, and to obtain any referrals your insurance may require.

Payment is expected when services are rendered. Delinquent accounts are subject to a 2% finance charge per month.

If insurance does not pay your claim within 90 days, you will be responsible for the amount in full. It is your responsibility to make sure that these claims are paid in a timely manner.

Please be advised that not all of our physicians are enrolled as a Medicaid provider. We recommend verifying your coverage with your insurance company, as you may be financially responsible for any charges they do not cover. I understand that should my account become past due it may be placed with a collection agency. If it is, I am aware that I am responsible for all collection agency fees (33 1/3%) of my account balance), attorney fees and court cost.

No Show / Late Cancellation: In order to provide timely care for all of our patients, we have a no show / late cancellation fee. A twenty-four hour cancellation of your appointment must be given to avoid being assessed a $50.00 charge for a missed appointment. If you miss a scheduled surgery appointment there will be a $100.00 fee. These fees are not covered by your insurance. There will be a $25.00 charge for any returned checks.

Print Name*

Signature*

Date*

Date

Date*

Date

Name*

Date of Birth*

Date

Height*

Weight*

How were you referred to us?*

FriendsDoctorInternetOther

Primary reason for today's visit*

How long have you had the problem?*

What treatment have you tried both nonprescription and or prescription*

Do you have or have you ever had Bronchitis?*

YesNo

Do you have or have you ever had Emphysema?*

YesNo

Do you have or have you ever had Asthma?*

YesNo

Do you smoke?*

YesNo

When was your last Flu Shot?

Do you have or have you ever had High Blood Pressue?*

YesNo

Do you have or have you ever had a Heart Attack?*

YesNo

Do you have or have you ever had a Heart Murmur/Rheumatic Fever?*

YesNo

Do you have or have you ever had Palpitation/Irregular or fast heartbeat?*

YesNo

Do you have or have you ever had Heart disease, angina or chest pain?*

YesNo

Do you have an Artificial Pacemaker/Defibrillator?*

YesNo

Have you ever had a Stroke?*

YesNo

Do you have or have you ever had Diabetes?*

YesNo

Do you have or have you ever had Thyroid Trouble?*

YesNo

Do you have or have you ever had Kidney or bladder problems?*

YesNo

Do you have or have you ever had Stomach or bowel problems?*

YesNo

Do you have or have you ever had Hepatitis, jaundice, liver disease?*

YesNo

Do you have or have you ever had convulsions or epilepsy?*

YesNo

Do you have or have you ever had problems with Fainting?*

YesNo

Do you have Glaucoma?*

YesNo

Do you have or have you ever had issues with Alcoholism?*

YesNo

Have you ever had Hepatitis B Exposure?*

YesNo

Have you ever had AIDS or HIV Exposure?*

YesNo

Do you have or have you ever had Cancer?*

YesNo

Have you ever had a Blood Transfusion?*

YesNo

Do you drink alcohol?*

YesNo

If yes how many per day?

How many per week?

Current medication and dosage, include over the counter, and vitamins*

Do you have any medication allergies and dosage, include over the counter, and vitamins*

YesNo

List of medication allergies

Other Medical Conditions or Surgeries not already listed?

Any personal history of skin cancer?*

YesNo

If yes, What type (If you know)

Any personal history of other skin disease?*

YesNo

If yes, What?

Any family history of skin cancer?*

YesNo

If yes, What type (if you know)?

Any family history of skin disease?*

YesNo

If yes,What?

Do you have any scarring tendencies after surgery?*

YesNo

If yes,What?

Women Only: Are you pregnant?

YesNo

If yes Due Date?

Date

When was your last menstrual period?

Who was this form completed by?*

PatientParent/Guardian

Signature*

Greenwood Dermatology 92 South Park Blvd Greenwood, IN 46143 317 889-7546 Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Greenwood Dermatology to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO (Greenwood'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. Greenwood Dermatology reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Greenwood Dermatology, 92 South Park Blvd, Greenwood IN 46143 Attn: Office Manager.

With this consent, Greenwood Dermatology may call my home or alternative location 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 any calls pertaining to my clinical care, including laboratory results among others.

With this consent, Greenwood Dermatology may mail to my home or alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, lab results, and patient statements. With this consent, Greenwood Dermatology may e-mail to my home or alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

You may have the following right with respect to your PHI: The right to request that Greenwood Dermatology 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. The right to reasonable request to receive confidential communication of PHI by alternative means or at alternative locations. The right to inspect and copy your PHI. The right to amend your PHI. The right to obtain a paper copy of this notice from us upon request. The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed. If you have paid for services "out of pocket", in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure. You must submit your request in writing to the office manager.

Do you give our office permission to discuss your medical information with a family member or care giver:*

YesNo

Name of family member/caregiver

Relationship

Name of family member/caregiver

Relationship

By signing this form, I am consenting to Greenwood Dermatology's use and disclosure of my PHI to carry out 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 Greenwood Dermatology may decline to provide treatment to me.

Signature of Patient or Legal Guardian*

Date*

Date

Please print patient name.*

DERMATOLOGY HISTORY FORM

Insurance cards & Photo ID