PATIENT REGISTRATION TODAY’S DATE ______
NAME ______SEX _____ AGE ______DOB ______
LAST FIRST M
ADDRESS ______
STREET APT# CITY ST ZIP
PHONE # HOME ______WORK ______CELL ______E-MAIL ______
SOCIAL SECURITY # ______EMPLOYER ______POSITION ______
EMPLOYER’S ADDRESS ______
SPOUSE/GUARDIAN
NAME ______HM # ______WK# ______
EMPLOYER ______POSITION ______
NEAREST RELATIVE NOT LIVING WITH YOU
NAME ______RELATIONSHIP ______
ADDRESS ______PHONE ______
BILLING INFORMATION: RESPONSIBLE PARTY
NAME ______HM# ______WK# ______
ADDRESS ______SEX ______DOB ______
SOCIAL SECURITY # ______EMPLOYER ______
EMPLOYER ADDRESS ______POSITION ______
RELATIONSHIP TO PATIENT ______
INSURANCE INFORMATION: IF YOU HAVE INSURANCE CARDS, DO NOT COMPLETE THIS SECTION. WE WILL PHOTOCOPY YOUR INSURANCE CARDS. PLEASE READ THE LAST SECTION, THEN SIGN AND DATE THIS FORM. CO-PAYMENTS ARE PAYABLE AT TIME OF CHECK-IN. THANK YOU.
PRIMARY INSURANCE ______INSURED’S NAME ______
ADDRESS ______PHONE # ______
ID # ______GROUP # ______
PATIENT’S RELATIONSHIP TO INSURED ______SELF ______SPOUSE ______CHILD ______OTHER
IF OTHER, PLEASE EXPLAIN ______
SECONDARY INSURANCE ______INSURED’S NAME ______
ADDRESS ______PHONE # ______
ID# ______GROUP # ______
PATIENT’S RELATIONSHIP TO INSURED ______SELF ______SPOUSE ______CHILD ______OTHER
IF OTHER, PLEASE EXPLAIN ______
I HEREBY AUTHORIZE THE RELEASE OF PERTINENT MEDICAL INFORMATION TO INSURANCE CARRIERS & AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO DRS. JAFFE, O’NEILL, AND LINDGREN, REALIZING I AM RESPONSIBLE TO PAY UNPAID SERVICES. THE MEDICAL SERVICES WHICH I RECEIVE TODAY WILL BE SUBMITTED TO MY INSURANCE COMPANY BASED ON THE INFORMATION I HAVE PROVIDED. IF PAYMENT HAS NOT BEEN RECEIVED WITHIN 60 DAYS FROM THE DATE OF SERVICE, OR DUE TO INCORRECT INSURANCE INFORMATION, THE CHARGES BECOME MY RESPONSIBILTY AND WILL BE DUE IN FULL AT THAT TIME. OUTSTANDING OR UNPAID PATIENT PORTION BALANCES GREATER THAN 60 DAYS WILL BE ASSESSED A 12% ANNUAL FINANCE CHARGE WHICH WILL ALSO APPLY TO OUTSTANDING INSURANCE BALANCES.
I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE POLICIES AS STATED ABOVE AND HAVE ALSO READ AND UNDERSTAND THE NOTICE OF PRIVACY PRACTICES EXPLAINING THE PROTECTION OF MY INDIVIDUAL RIGHTS OF PRIVACY UNDER THE HIPAA ACT.
SIGNATURE ______DATE ______
PATIENT MEDICAL HISTORY
Name: ______Date: ______
Date of birth: ______Age: ______Sex: ______
Referring physician or friend ______
Family or primary care physician ______
MEDICAL HISTORY: (please check all that apply and detail if necessary)
______anemia______asthma/hay fever______diabetes______heart
______liver______kidney______cancer (other than skin)______arthritis
______peptic ulcer______tuberculosis______hepatitis______other-infections diseases
______bleeding problems______prior surgery______surgical problems
______hives______eczema______psoriasis or other skin diseases
Details (if necessary): ______
______
Skin cancer(s) or precancers: ______
______
MEDICATIONS: ______
______
ALLERGIES: ______
______
______
FAMILY HISTORY: (skin cancers or significant dermatologic problems)
______
REASON FOR TODAY’S VISIT: ______
______
______
HOW HAVE YOU BEEN TREATED FOR THIS PROBLEM?: ______
______