Patient History Form

Today's Date *

Full Name*

Medical History

History of melanoma*

Yes

History of squamous cell carcinoma (SCC)*

Yes

History of basal cell carcinoma (BCC) *

Yes

Change in size, shape, color or sensation in any moles or growths*

Yes

Hypertension (HTN) [High Blood Pressure]*

Yes

Hypercholesterolemia [High Cholesterol]*

Yes

Diabetes*

Yes

History of HIV/Hepatitis*

Yes

Neurological disorders*

Yes

Cancer*

Yes

Asthma/allergies*

Yes

Thyroid disease*

Yes

Pacemaker*

Yes

Bleeding Disorder*

Yes

Cardiac Valve Disease/Mitral Valve Prolapse*

Yes

Joint Replacement*

Yes

Joint pain/arthritis*

Yes

Autoimmune disease*

Yes

Currently Pregnant*

Yes

Currently Breast feeding*

Yes

Current Irregular periods*

Yes

Family History

Melanoma*

Yes

Social History

Are you a?*

Current Smoker

Former Smoker

Non-Smoker

How often did you have a drink containing alcohol in the past year?*

Never

Monthly or less

2 to 4 times a month

2 to 3 times a week

4 or more times a week

6 or more times a week

THIS SECTION MUST BE COMPLETED BY ALL NEW PATIENTS

First Name*

Last Name*

Middle Name

Permanent Mailing Address*

City*

State*

Zip*

Primary Phone*

Other Phone

Patient's Occupation

Work Phone

Ext

Date of Birth*

Age*

Sex*

Male

Female

Email address*

Race

Ethnicity

Preferred Language

May we contact you at*

Primary

Other

Work

May we leave a message on your answering machine regarding lab / visit / biopsy results?*

Yes

May we leave a message with any other person?*

Yes

Emergency Contact*

Relationship*

Contact Number*

Preferred Pharmacy

Street Name

Phone #

Is responsible party different from patient?*

Yes

RESPONSIBLE PARTY - If responsible party is different from patient, this section must be completed.

First Name

Last Name

Middle Name

Address

City

State

Zip

Primary Phone

Other Phone

Date of Birth

Sex

Male

Female

Primary Care Physician*

Referred By

How did you hear about us (friend, TV, ad, internet, yellow pages, etc. - please describe)?*

I authorize release of medical information to my Primary Care Dr. / Referring Physician / other consultants if needed.*

I understand that if I am scheduling a visit for a problem focused dermatology issue unrelated to skin cancer, a full body skin cancer screening may not be completed at that visit. Should you or your provider ultimately request a comprehensive skin cancer screening, this may need to be scheduled separately.*

Insurance Coverage - Primary

Are you a self-pay patient or do you have insurance?

Self-Pay

Insurance

Conditions of Registration and Financial Policy

The following are our conditions of registration as well as our policies with respect to the billing and collections of your account. By signing below, you are agreeing to be bound by these terms.

Basic Policy:

Payment is due in full at the time service is provided in our office.

For Patients With Medicare:

We will bill Medicare on your behalf. As a courtesy, we will also bill secondary insurance carriers on your behalf. You are responsible for all co-insurance payments.

For Patients With Insurance:

All co-payments, coinsurances and deductibles are due at the time of service. As a policy we will collect $50 at the time of visit to cover a portion of any coinsurance or deductible that may be due as we cannot determine these actual amounts until the claim has processed by our insurance. In the case where your insurance card/coverage stipulates a Copayment, we will collect the amount defined on your card which may be more or less than $50. We will bill insurance carriers on your behalf if we have a current contract with the carrier. After your insurance has processed the claim, we will be able to determine whether any refunds are due for overpayments towards copayment, coinsurance or deductible and those will be sent to the patient. Please be advised that your agreement with your insurance carrier is a private one and that ultimately, you are responsible for payment. If an insurance carrier has not paid a claim within 60 days of billing, our fees are due and payable from you. Our office will always strive to help you obtain the maximum possible coverage. It is, however, the patient's ultimate responsibility to determine the extent of coverage allowed by the insurance company.

In addition, preauthorization of a procedure is not a guarantee for payment. Any procedure may be considered not covered under the terms of your agreement with your insurance company. Your insurance carrier will make a determination of payment once the claim is received and reviewed . If after the claim is reviewed and it is determined by your insurance company that the procedure is not covered (cosmetic or not medically necessary), you will be financially responsible to Wilmington Dermatology Center, PLLC for the charges and will be billed for those services not covered by your insurance company.

Patients Who Have A Biopsy Performed In Our Office (Insurance & Self Pay):

A biopsy procedure may be performed in our office to assist in diagnosing your skin condition. Biopsies are submitted by Wilmington Dermatology Center (WDC) to a 3rd party board certified dermatopathology provider independent from WDC. The dermatopathology company evaluates the biopsy via microscope and returns a diagnostic interpretation. The act of evaluating your biopsy, performing any testing, and returning a report of their findings is directly billed by the pathology company to you or your insurance, not by WDC. We follow the approach approved by the American Academy of Dermatology for pathology billing, which eliminates any conflicts of interest and avoids any markups that would benefit the dermatologist if they billed for these external services.

Self Pay Patients:

Individuals without insurance coverage or insurances that are not contracted with WDC can be seen as Self-Pay patients. Self-Pay patients pay for treatment at the time of their service based on average market rates WDC establishes for procedures completed. WDC will not provide insurance-based coding for anyone seen as a Self-Pay patient for the purposes of the patient submitting a claim for services rendered.

Noncovered Services:

Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or immediately upon notice of insurance claim denial.

Missed Appointments:

In fairness to other patients and the doctor, we require at least 24 hours notice to cancel an appointment. You may be charged $50.00 for each appointment that was missed or not canceled with 24 hour notice. Missing more than two appointments without providing 24 hours notice is grounds for discharge from the practice.

Returned Checks:

There will be a fee of $25.00 charged by this office for each check returned to us by your bank.

Collection Agency Costs:

In the event your account is referred to a collection agency or attorney for collection, you agree to pay all collection fees, attorney fees, court costs, and expenses.

Signatures

MEDICARE PATIENTS ONLY:

SIGNATURE ON FILE. I request and authorize payments of Medicare benefits be made to Wilmington Dermatology Center, PLLC for any services furnished me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Service and its agents any information needed to adjudicate these benefits for services. I understand my signature requests that payment be made and authorizes release of all information necessary to adjudicate the claim. If "other health insurance" is indicated, my signature authorizes the release of all information to the insurer or agency that is necessary to adjudicate the claim. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and that I am responsible for the deductible, coinsurance, and any non-covered services.

All Patients*

ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plans, to Wilmington Dermatology Center, PLLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not the charges are paid by said insurance. I hereby authorized said assignee to release all information necessary to adjudicate all claims and secure payment for services rendered .

If you have a supplemental policy and it is a MEDIGAP policy to which your Medicare Carrier automatically "crosses over", we are required to keep a separate signature on file

I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to the above MEDIGAP carrier any information needed to determine these benefits or the benefits payable for related services.

All Patients*

I have read, understood, and agree to be bound by the terms of this financial policy.

Notice of Privacy Practices

I hereby acknowledge that I had the opportunity to review the Notice of Privacy Practices of Wilmington Dermatology Center, PLLC. I understand that the Notice of Privacy Practices sets forth my rights relating to the use and disclosure of my personal health information and explains how Wilmington Dermatology Center, PLLC can use and/or disclose my personal health information both with and without my authorization. I understand that I am entitled to receive a copy of the Notice of Privacy Practices* if I so desire. I further understand that I may contact Dr. George if I have any questions regarding the contents of this Notice of Privacy Practices or to file a complaint about the privacy practices of Wilmington Dermatology Center, PLLC.

By signing I am providing my signature agreeing to authorizations and assignments defined above in the signature section for those areas checked.

Signature*
Use your mouse or touch screen to sign in the block below

(Reset Signature)

*A copy of our Notice of Privacy Practices can be found on our web site, here

Skin Care Questionnaire

Do you follow a structured skin care regimen today?

Yes

If Yes - Describe your regimen

Would you best describe your skin as oily, dry, or a combination?

How would you describe your skin's sensitivity?

Low

Moderate

High

What are your primary skin-related concerns / goals?

Facial Goals:

Select your area(s) of concern and identify the location in the space provided .

Correct Facial Sagging, Eyebrow Drop, improve jaw line definition Yes

Location - Correct Facial Sagging, Eyebrow Drop, improve jaw line definition

Improve volume in areas (cheeks, lips, etc) Yes

Location - Improve volume in areas (cheeks, lips, etc)

Correct facial wrinkles/creases Yes

Location - Correct facial wrinkles/creases

Improve acne / rosacea Yes

Location - Improve acne / rosacea

Get rid of facial veins and/or redness Yes

Location - Get rid of facial veins and/or redness

Correct scarring Yes

Location - Correct scarring

Correct sunspots Yes

Location - Correct sunspots

Correct precancerous spots Yes

Location - Correct precancerous spots

Improve general appearance of skin tone / health Yes

Location - Improve general appearance of skin tone / health

Lengthen and thicken eyelashes Yes

Location - Lengthen and thicken eyelashes

Minimize the appearance of under eye bags Yes

Location - Minimize the appearance of under eye bags

Body Related Goals: Select your area(s) of concern and identify the location in the space provided .

Remove unwanted areas of fat Yes

Location - Remove unwanted areas of fat

Address Hair Loss Yes

Location - Address Hair Loss

Remove Cellulite Yes

Location - Remove unwanted areas of cellulite

Remove tattoos Yes

Location - Remove tattoos

Tighten loose skin on arms, and above knees Yes

Location - Tighten loose skin on arms, and above knees

Improve texture of skin (ex. Bumps on backs of arms) Yes

Location - Improve texture of skin (ex. Bumps on backs of arms)

Manage chronic skin conditions (ex. psoriasis, eczema) Yes

Location - Manage chronic skin conditions (ex. psoriasis, eczema)

Remove unwanted areas of hair Yes

Location - Remove unwanted areas of hair

Underarm sweating Yes

Location - Underarm sweating

Do you have an interest in participating in clinical research studies?

Yes

If Yes - Describe your area of interest (ex. Psoriasis, acne,etc)

Submit Form