HIPAA Certified Compliance

PATIENT REGISTRATION FORM: PLEASE ANSWER ALL QUESTIONS 

Date:
Insurance Information

Please use your most current insurance ID card to complete the following fields.

Primary Insurance

Medical History

Please complete all questions as accurately as possible.

Past Medical History

Select YES or NO if you currently have any of the following conditions.

Past Surgical History

Have you ever had the following?

Skin History

Have you ever had or currently have the following?

Skin Cancer History

Please list any prior skin cancers.

PAST PLASTIC SURGICAL HISTORY

Have you ever had the following?

Malignant Hyperthermia and Anesthesia History
Medications

List ALL prescriptions, over-the-counter, herbal, and/or vitamin(s). Complete medication name, strength, dose, route, and frequency. If your medication list is more than our form allows, please bring your list to your next visit.

Allergies

List your allergies and reaction.

Social History

Answer with the best response.

FAMILY MEDICAL HISTORY

List major medical conditions of first-degree relatives.

Review of Systems

Have you had any of the following in the past year?

Alerts

Please answer the following important questions.


Vaccinations
ADVANCE CARE PLAN (For all pts. 65 and older)

Medicare

 

HIPAA Privacy Form

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 a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

 

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to the uses or disclosures made pursuant to an authorization requested by an individual.

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.

clear signature area

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

Financial Policy and Assignment of Insurance Benefits

I hereby authorize and direct my insurance carrier to issue payment directly to Piedmont Plastic Surgery & Dermatology for medical services rendered to me and/or my dependents. I understand that I am responsible for any amount not covered by insurance. Payments and credits are applied to the oldest charges first, except for insurance payments, which are applied to the corresponding charges. I agree that if my insurance carrier sends payment to me for the medical services instead of to PPSD, I will immediately pay the amount due to PPSD. I agree it is my responsibility to understand my insurance benefits and to notify Piedmont Plastic Surgery & Dermatology immediately of any changes to my insurance coverage. I understand that it is my responsibility to obtain insurance authorization if it is required, and the payment is still my responsibility. Please remember that insurance is a contract between the patient and the insurance company, and ultimately you are responsible for payment in full to Piedmont Plastic Surgery & Dermatology.

I agree for Piedmont Plastic Surgery & Dermatology to service my account or to collect any amounts I owe. I may be contacted by telephone at any number associated with my account, including wireless telephone numbers, which could result in charges to me. I may also receive text messages or emails, using any email address I provide. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing device, as applicable. I authorize review, recording, and downloading of my prescription history records from the internet and/or other doctors’ data. I also authorize photography of my medical/surgical conditions and for my medical record ID. Patients whose accounts have been turned over to a collection agency will be responsible for the account balance and all costs associated with collection, including attorney fees. There will be a charge for form completion: disability, FMLA, supplemental insurance, etc. The forms require office staff time and time away from patient care for the physicians. We require 3 business days to complete the forms and requests. I authorize Piedmont Plastic Surgery & Dermatology to use and disclose the health and medical information for the purposes of treatment, payment, and health care operations. I understand I may review Piedmont Plastic Surgery & Dermatology’s “Notice of Privacy Practices” for additional information about the uses and disclosures of information described in this consent prior to signing this consent.

Reset Signature

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

Reset Signature

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

Cancel, No-Show, and Late Arrival Policy

Due to the high volume of patients that need specialist services and the importance of attending all scheduled visits, Piedmont Plastic Surgery & Dermatology (PPSD) has established the following guidelines regarding canceled, no-show, and late arrival appointments. Your cooperation is greatly appreciated.

Cancel, No-Show Policy

 

Late Policy

 

I have read and understand PPSD’s Cancel, No-Show, and Late Arrival Policy.

Reset Signature

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

 

Please review your entries before submitting.


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