Katy D e r m a t o l o g y . P.A.
Patient
Date of Birth
Medical History Q u e s t i o n n a i r e
PAST MEDICAL
HISTORY
Please c h e c k if you have a history of:
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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Thyroid Disease
Allergies/Sinusitis
Asthma
Emphysema / COPD
Tuberculosis
GERD (Reflux Disease)
Irritable Bowel Syndrome
Stomach Ulcer
Osteoporosis
Medication-CURRENTLY
Females Only:
TAKING
Diabetes Mellitus
High Cholesterol
Hypertension
Heart Attack
Congestive Heart Failure
Heart Arrhythmias
Mitral Valve Prolapse
Rheumatic Fever
Artificial Heart Valve
•
•
•
•
•
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Artificial Joint (hip, knee)
Cataracts
Glaucoma
Cancer (other than skin)
o Which type?
HIV
Hepatitis
Other Medical Problems
Taken for
Are you currently pregnant or actively trying to get pregnant?
•
YES
•
Personal Dermatologic History. Please check if you have a history of:
•
Eczema
•
Psoriasis
•
Lupus
•
Scarring Acne
•
Actinic Keratosis (Precancerous Skin Growth)
•
Skin Cancer
o Which Type?
Melanoma,
Basal Cell,
Squamous Cell,
Other
Year you were diagnosed?.
SOCIAL
HISTORY
Do you s m o k e ?
YES
NO
Do you u s e tanning booths?
YES
NO
Do you wear s u n s c r e e n regularly?
YES
NO
FAMILY ILLNESS
- Check if there is any history in your family of:
Disease
Family Member
Skin Cancer (other than melanoma)
Melanoma
Asthma / Eczema / Seasonal Allergies
Psoriasis
Allergies to medication?
• YES
Medication
NO If yes, please list:
Taken for
PHARMACY
Pharmacv
•
INFORMATION
Phone
Location
21310 Provincial Blvd., Katy, Texas 77450 - Phone (281) 599-0404 Fax: (281) 599-1655
www.katydermatology.com
NO
Katy Dermatology. PA
PATIENT INFORMATION
Patient's last name:
Is this your legal name?
| Middle:
| First:
• Mr.
• Mrs.
(Former name):
If not, what is your legal name?
Marital status (circle one)
• Miss
• Ms.
Single / Mar / Div / Sep / Wid
Birth date:
An
3 9 6
• Yes
e
X
:
FEMALE
• No
Home phone no.:
Social Security no.:
Street address:
(
P.O. Box:
City:
Occupation:
Employer:
)
State:
ZIP Code;
Employer phone no.
(
• Dr.
Chose clinic because/Referred to clinic by (please check one box):
• Family
S
MALE
U Friend
• Close to home/work
)
• Insurance Plan
• Hospital
• Other
• Yellow Pages
Other family members seen here:
INSURANCE INFORMATION
Person responsible for bill:
Address (if different):
Birth date:
/
Home phone no.:
/
(
P O L I C Y NUMBER
PRIMARY INSURANCE:
)
GROUP NUMBER
Subscriber's S.S. #
Subscriber's name:
Birth date:
/
Patient's relationship to subscriber:
S E C O N D A R Y I N S U R A N C E (if a p p l i c a b l e ) :
Patient's relationship to subscriber:
• Spouse
• Self
• Child
POLICY #
Subscriber's name:
• Self
E M E R G E N C Y C O N T A C T : (not living at same address):
• Spouse
• Child
/
• Other
GROUP*
• Other
Relationship to patient:
Home phone #
Work phone #
(
(
)
)
Office Policies: Insurance Co-payments will n o t be billed to you as payment is due at the time of service. If you do not provide proper insurance
information and identification for insurance filing, you will be considered private pay. Full payment for services will be due at the time of service. 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 cancel the appointment at least 24 hours in advance. Failure to
cancel an appointment within 24 hours will result in the assessment of a $ 2 5 f e e .
I certify t h a t t h e a b o v e information i s t r u e t o t h e b e s t of 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 to be p a i d directly to 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 to p r o c e s s m y i n s u r a n c e c l a i m . I t i s m y responsibility t o notify
m y p h y s i c i a n of a n y c h a n g e s to 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 information, i n s u r a n c e a n d m e d i c a l conditions.
Patient/Guardian signature
Date
2 1 3 1 0 P r o v i n c i a l Blvd., Katy, T e x a s 7 7 4 5 0 - w w w . k a t y d e r m a t o l o g y . c o m
P h o n e : ( 2 8 1 ) 5 9 9 - 0 4 0 4 - Fax: ( 2 8 1 ) 5 9 9 - 1 6 5 5
Katy 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 t o 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 t o request confidential communications
or that communication of PHI be made by alternative means, such as sending correspondence t o home or office,
leaving messages on answering machines, and leaving lab or procedure results with a spouse of other family
member.
I wish t o be contacted in the following manner feheek a l l t h a t appliasV
n Home Telephone
• Permission t o leave message with detailed information
• Permission to leave message with call-back number only
a Cellular Telephone
• Permission t o leave message with detailed information
• Permission t o leave message with call-back number only
• Work Telephone
n Permission t o leave message with detailed information
• Permission t o leave message with call-back number only
• Written Communication
o Mail t o my home address
• Permission to fax to this number:
List all person(s) in which we have permission t o discuss and/or leave detailed information regarding your care,
diagnosis and/or lab results:
Name
Relationship
Name
Relationship
Name
Relationship,
This consent will remain in effect unless otherwise revoked in writing.
Patient/Guardian's Signature
Date
2 1 3 1 0 P r o v i n c i a l Blvd., Katy, Texas 7 7 4 5 0 - w w w . k a t y d e r m a t o l o g y . c o m
P h o n e : ( 2 8 1 ) 5 9 9 - 0 4 0 4 - Fax: ( 2 8 1 ) 5 9 9 - 1 6 5 5
Katy Dermatology, PA
PAYMENT FOR SERVICES
( P l e a s e sign at t h e b o t t o m of page)
Dear Patient or Guardian:
We are committed t o providing you with the best possible care, and we are pleased t o discuss our professional fees
with you at any time. Your clear understanding of our financial policy is important t o our relationship. This form is t o
provide information and prevent misunderstandings regarding payment of physician services.
F i n a n c i a l Policy
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 inoffice/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 o f 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 t o injections, biopsies, excisions or wart treatment, may be applied to the annual deductible of your plan.
Ultimately, it is your responsibility t o know what provisions, restrictions and requirements are included or excluded in
your specific health insurance policy. I f there is any uncertainty about coverage, we will be happy t o provide you with
an estimate of our fees before treatment begins.
Referrals: I f your insurance requires that you have a referral to see us, it is your responsibility or your primary care
physician's responsibility t o deliver the referral to this office prior t o or at the time of your visit. A referral is not a
guarantee of payment by your insurance company.
Payment at the lime of service: Any copayment or coinsurance including deductibles must be paid at the time of
service. Payment may be made by cash, check, Visa or MasterCard.
I f 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 t o send all surgically removed specimens t o 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 t o 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 Authorization 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 t o the insurance company that I am covered under, and t o any physicians whom, in the course of
my treatment I may agree t o see at physicians' request. I therefore, authorize and assign payment t o 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
2 1 3 1 0 Provincial Blvd., Katy, T e x a s 7 7 4 5 0 - w w w . k a t y d e r m a t o l o g y . c o m
P h o n e : ( 2 8 1 ) 5 9 9 - 0 4 0 4 - Fax: ( 2 8 1 ) 5 9 9 - 1 6 5 5
Date