Katy Dermatology. PA

P A T I E N T I N F O R M A T I O N

Patient's last name: First: Middle: • Mr.

• Mrs.

• Miss

• Ms.

Marital s tatus (circle one)

Single / Mar / Div / Sep / Wid

I s this your legal n a m e ?

• Y e s • No

If not, what is your legal n a m e ? ( F o m i e r n a m e ) : Birth date; . Sex:

= ^ MALE FEMALE

Street address : Social Security no. : Home phone no.:

( )

P.O. Box: City: State: Z I P Code:

Occupation; Employer: Employer phone no.:

( )

Chose clinic t jecause/Referred to clinic by (p lease ctiedc one box) : • Dr. • Insurance Plan • Hospital

• Family • Friend • O o s e to home/woric • Yel low P a g e s • Other

Other family m e m b e r s s e e n here:

I N S U R A N C E I N F O R M A T I O N

Person responsible for bill: Birth date:

/ / Address (if different): Home phone no.:

( )

P R I M A R Y I N S U R A N C E : P O U C Y N U M B E R : G R O U P N U M B E R

Subscr iber 's name: Subscr iber 's S .S . # Birth date:

/ /

Patient's relationship to subscr iber: • Self • Spouse • Child • Other

S E C O N D A R Y I N S U R A N C E ( i f a p p l i c a b l e ) : Subscr iber 's n a m e : P O L I C Y # 6 R O U P #

Patient's relationship to subscr iber: • Self • S p o u s e • Child • Other

E M E R G E N C Y C O N T A C T : (not living at s a m e a d d r e s s ) : Relationship to patient; Home phone #

( )

Woric phone #

( )

O f f i c e P o l i c i e s : Insurance Co-payments will n o t be billed to you a s payment is due at the t ime of serv ice. I f you do not provide proper insurance

information and identification for insurance filing, you will be considered private pay. Full payment for serv ices will tje due at the time of serv ice. No

claims will be filed on your behalf if you have not presented insurance identification.

If you are unable to attend a s c h e d u l e d a p p o i n t m e n t , you are required to call and cance l the appointment at least 24 hours in advance . Failure to

cancel an appointment within 24 hours will result in the a s s e s s m e n t of a $ 2 5 f e e .

I c e r t i f y t h a t t h e a b o v e i n f o r m a t i o n i s t r u e t o t h e b e s t o f m y k n o w l e d g e . I a u t h o r i z e m y i n s u r a n c e b e n e f i t s t o b e p a i d d i r e c t l y t o m y

p h y s i c i a n . I a u t h o r i z e m y p h y s i c i a n t o r e l e a s e i n f o r m a t i o n r e q u i r e d t o p r o c e s s m y i n s u r a n c e d a i m . I t i s m y r e s p o n s i b i l i t y t o n o t i f y

m y p h y s i c i a n o f a n y c h a n g e s t o m y n a m e , a d d r e s s , t e l e p h o n e n u m b e r , p h a r m a c y i n f o r m a t i o n , i n s u r a n c e a n d m e d i c a l c o n d i t i o n s .

Patient/Guardian signature Date

21310 Provincial Blvd., Katy, Texas 77450 - www.katyde-mato logy.com Phone: (281) 599-0404 - Fax: (281) 599-1655

Katv Dermatoloav. P.A.

Patient Date of Birth

Medical History Questionnaire PA<^TMFniCAI HI<iTORY P l e a s e c h e c k if you have a history of:

• Thyro id Disease • Al lergies/Sinusit is • As thma • Emphysema / COPD • Tuberculos is • GERD (Ref lux Disease) • Irritable Bowel Syndrome • S tomach Ulcer • Osteoporos is • Diabetes Mel l i tus • High Cholestero l • Hypertens ion

• Heart Attack • Congest ive Heart Fai lure • Heart Ar rhythmias • Mitral Va lve Pro lapse • Rheumat ic Fever • Artif icial Heart Va lve • Artif icial Joint (hip, knee) • Cataracts • G laucoma • Cancer (other than skin cancer)

o Wh i ch tvpe?

• H IV • H e p a t i t i s

For W o m e n : A re you current ly pregnant or actively try ing to get pregnant? Yes No

P e r s o n a l Dermato log ic History. P l e a s e c h e c k if you have a history of: • Eczema • Psoriasis • Lupus • Scarr ing Acne • Actinic Keratosis (Precancerous Skin Growth) • Skin Cancer

o Wh ich Type? Me lanoma Basal Cell Cancer Squamous Cell Cancer Other

SOCIAL HISTORY

Do you smoke? Yes No

Do you use tanning booths? Yes No

Do you wear sunscreen regularly? Yes No

FAMILY HISTORY

Do any m e m b e r s of y o u r family suf fer from the fo l lowing?

Disease Family Member

Skin Cancer (other than me lanoma)

Me lanoma

As thma / Eczema / Seasona l Al lergies

Psoriasis

PHARMACY INFORMATION

Pharmacv Phone

Location

21310 Provincial Blvd. Katy, Texas 77450 - Phone: (281) 599-0404 Fax: (281) 599-1655 www.katydennatology.com

Katv Dermatology. PA

PAYMENT FOR SERVICES

(Please sign at the bottom of page)

Dear Patient or Guardian;

We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees

with you at any time. Your clear understanding of our financial policy is important to our relationship. This form is to

provide information and prevent misunderstandings regarding payment of physician services.

F i n a n c i a l P o l i c y

Your Responsibility. Insurance coverage is not a guarantee of payment. There are several reasons why your

insurance may not pay for your visit. These include:

• You have not met your annual deductible. Many policies have a separate, higher deductible for in-

office/outpatient surgical procedures.

• You have not received the proper referral or preauthorization for the visit or procedure.

• The services or procedures are not covered by your insurance. These policies vary greatly among insurance

companies and plans. Examples might include certain types of cosmetic treatment, such as chemical peels,

Botox and removal of certain non-cancerous growths such a skin tags.

• We are currently not contracted with your insurance carrier.

We will inform you when we know a treatment or procedure will not be covered by your insurance, but many times it

is not possible for us to know with certainty. Often, insurance companies will not make a determination until they

have received the claim. Office visit copays in most cases cover only the office visit itself, and services including but

not limited to injections, biopsies, excisions or wart treatment, may be applied to the annual deductible of your plan.

Ultimately, it is your responsibility to know what provisions, restrictions and requirements are included or excluded in

your specific health insurance policy. I f there is any uncertainty atx)ut coverage, we will be happy to provide you with

an estimate of our fees before treatment begins.

Referrals: If your insurance requires that you have a referral to see us, it is your responsibility or your primary care

physician's responsibility to deliver the referral to this office prior to or at the time of your visit. A referral is not a

guarantee of payment by your insurance company.

Payment at the time of senfice: Any copayment or coinsurance including deductibles must be paid at the time of

service. Payment may be made by cash, check. Visa or MasterCard. If both covered and non-covered services are

performed at the same visit, you must pay your copayment as well as the non-covered service. Returned checks will

incur a $25 administrative fee.

Laboratory/Pathology Services: I t is the policy of this office to send all surgically removed specimens to expert

consultation regardless of the pre-biopsy or pre-surgery diagnosis. You are responsible for any charges not covered

by your health insurance. These charges will be billed to you separately and are not included in the charges from our

office. The laboratory will bill your insurance as long as you have provided us accurate information.

I n s u r a n c e A u t h o r i z a t i o n a n d A s s i g n m e n t

If insurance is filed on my behalf, I authorize Katy Dermatology, P.A. to release any information acquired in the

course of my case to the insurance company that I am covered under, and to any physicians whom, in the course of

my treatment I may agree to see at physicians' request. I therefore, authorize and assign payment to Katy

Dermatology, P.A. for any services rendered. I understand that I am financially responsible for any unpaid balance

not covered by this assignment of benefits.

Signature of Patient or Responsible Party Date

21310 Provincial Blvd., Katy, Texas 77450 - www.katydermato logy.com Phone: (281) 599-0404 - Fax: (281) 599-1655

Katv Dermatology. PA

NOTICE OF PRIVACY PRACTICES

Katy Dermatology, P.A.'s "Notice of Privacy Practices" is located in a binder at the front window as well as in each

exam room.

I have received and/or been offered a chance to read Katy Dermatology, P.A.'s "Notice of Privacy Practices" which

explains how my medical information will be used and disclosed, as required by the HIPAA Privacy Rule.

PATIENT RECORD OF DISCLOSURES

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their

protected health information (PHI). The individual is also provided the right to request confidential communications

or that communication of PHI be made by alternative means, such as sending correspondence to home or office,

leaving messages on answering machines, and leaving lab or procedure results with a spouse of other family

member.

I wish to be contacted in the following manner f check all that appliasV

• Home Telephone

• Permission to leave message with detailed information

• Permission to leave message with call-back number only

• Cellular Telephone

• Permission to leave message with detailed information

• Permission to leave message with call-back number only

• Work Telephone

• Permission to leave message with detailed information

• Permission to leave message with call-tock number only

• Written Communication

• Mail to my home address

• Permission to fax to this number:

List all person(s) in which we have permission to discuss and/or leave detailed information regarding your rare, diagnosis and/or lab results:

Name Relationship

Name Relationship

Name Relationship

This consent will remain in effect unless otherwise revoked in writing.

Pat ient/Guard ian 's Signature Date

21310 Provincial Blvd. Katy, Texas 77450 - Phone: (281) 599-0404 Fax: (281) 599-1655 www.katydermatology.com