AMETHYST MEDICAL GROUP - Dermatology Consultants



|2424 Harrodsburg Road, Suite 200 |

|Lexington, Kentucky 40503 |

|PATIENT REGISTRATION FORM |

|Last Name: |First Name: |M.I. |

|SSN: |Date of Birth: |Sex: Male ( Female ( |

|Marital Status: Single Married Divorced Widowed |Race: |

|Mailing Address: |

|City: |State: |Zip: |

|Employer: |Occupation: |

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|Home Phone __________ -___________ -_____________ Cell Phone__________ -___________ -___________ |

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|Work Phone __________ -___________ -_____________ Email ______________________________________ |

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|By providing my wireless telephone number, I am consenting to receiving communications via calls or text messages including but not limited to information regarding |

|appointments, payments, prescriptions, labs, and pathologies. |

|By providing my email address, I consent to receiving statements, bills, and marketing material for dermatology and cosmetic services via email. |

|Signed: ____________________________________________________ Date: _______________________________ |

|How did you hear about us? |

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|Primary Care/Referring Physician:_____________________________________________________________________ |

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|I hereby authorize the release of my medical record or any information contained in the record to primary care and/or referring physicians. |

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|Signed:_____________________________________________________ Date:_______________________________ |

|Emergency Contact: |

|Name: ____________________________________ Relationship: _____________________________________ |

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|Phone: __________- __________- __________ |

|Insurance: |

|Primary Insurance Name:____________________________________________________________________________ |

|Secondary Insurance Name:__________________________________________________________________________ |

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|Consent to Treat: |

|I hereby consent to examination and treatment by Dermatology Consultants including diagnostic and/or therapeutic procedures ordered by the physician. |

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|Signed:____________________________________________________ Date:_______________________________ |

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Receipt of Notice of Privacy Practices

Written Acknowledgement Form

As a patient of Dermatology Consultants, I hereby acknowledge receipt of Dermatology Consultants’ Notice of Privacy Practices

Name [print please]: ________________________________________________________________________________

Patient Signature/Legal Representative: ________________________________________________________________

Relationship:________________________________________________________Date: __________________________

For office use only:

____ Patient refused or unable to sign

Designation of Personal Representative

As required by the Health Insurance Portability and Accountability Act of 1996 you have a right to nominate one or more persons to act on your behalf with respect to the protection of health information that pertains to you. By completing this form you are informing us of your wish to designate the name(s) of the person(s) as your personal representative. You may revoke this designation at any time by signing and dating the revocation of your copy of this form and returning it to this office. Please choose ONE of the following options.

The person(s) is to be afforded all of the privileges that would be afforded to me with respect to my health information.

I understand that I may revoke this designation at any time by signing the revocation section of my copy of this form and returning it to Privacy Officer, Dermatology Consultants, P.S.C., 2424 Harrodsburg Road, Suite 200, Lexington, KY 40503. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this designation.

Designation Section

I, ____________________________________ (print name) hereby nominate the following person (s) to act as my personal representative with respect to decisions involving the use and/or disclosure of health information that pertains to me.

Print Name of Personal Representative #1__________________________________________________________

Print Name of Personal Representative #2_________________________________________________________ _

Patient Declines Personal Representative

Signature Date

Revocation Section

I hereby revoke this designation of a personal representative.

Signature Date

Financial Policy

• PAYMENT: Copays are due at time of service. We accept cash, checks, Visa, Mastercard, American Express and Discover. A $25 fee will be billed to you in the event of a returned check. We will notify you via mail if your check has been returned and you will have 10 days to pay the balance or you may be turned over to a collection agency.

• NON-INSURED PATIENTS: Patients who do not have insurance are always welcome at Dermatology Consultants. Payment in full is due at time services are rendered. A 15% discount is applied to all charges.

• OUTSTANDING BALANCE: Delinquent balances must be paid in full before additional services can be provided unless other arrangements have been made through our billing office. Delinquent balances over 90 days old may be turned over to a collection agency. Dermatology Consultants reserves the right to dismiss patients with delinquent accounts.

• CANCELLATIONS OR MISSED APPOINTMENTS: A 24 hour notice is required for all Patch Test and Surgical appointments. A $100 fee will be charged for any missed appointments/cancellations made with less than 24 hours notice.

• INSURANCE: It is your responsibility to provide our practice with current/active insurance information. If you cannot provide your current/active insurance information, you will be responsible for the entire balance. Please check with your insurance to see if we are an in-network provider. If our doctors are not listed in your plan, you may be responsible for the entire bill. Your insurance company and your plan benefits ultimately determine the amount paid. All charges you incur are your responsibility regardless of insurance coverage.

• MINORS: A parent or legal guardian must accompany all children under the age of 18. The parent bringing the child in for service will be responsible for the bill.

______________________________________ ________________

Signed Date

Release of Information/Assignment of Benefits

• I authorize the release of my medical record or any information contained in this record to primary care and/or referring physicians.

• I authorize Dermatology Consultants to release information necessary to secure payment on my behalf or on the behalf of my dependents. I authorize payment directly to Dermatology Consultants for medical treatment on any and all medical services rendered. I further understand that I am responsible for all fees not paid by my insurance and the balance is due within 30 days receipt of a patient statement. This authorization remains valid unless revoked in writing.

______________________________________ __________________

Signed Date

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Medical History

Patient:______________________________________ Date of Birth: _______________ Today’s Date:_______________

Medication Allergies:

1._________________________________________________ 3.______________________________________________

2._________________________________________________ 4.______________________________________________

Current Medications:

1.________________________________ 3._______________________________ 5.______________________________

2.________________________________ 4._______________________________ 6.______________________________

Primary Care Physician: First Name:_________________Last Name:___________________City:___________________

Preferred pharmacy: _________________________________________________________

Have you had a flu shot? ( Yes ( No If yes, when? Month___________Day__________ Year__________

Have you had a pneumonia shot? If yes, Month_______________, Year___________

Past History:

Lungs: Yes No Other Systemic : Yes No

Seasonal Allergies ( ( Diabetes ( (

Asthma ( ( Thyroid ( ( If yes, ______________

Cardiovascular: Kidney ( ( If yes, ______________

High Blood Pressure ( ( Bladder ( ( If yes, ______________

Irregular Heartbeat ( ( Gastrointestinal ( ( If yes, ______________

Pacemaker ( ( Arthritis ( ( If yes, ______________

Defibrillator ( ( Artificial Joints ( ( If yes, ______________

Heart Attack ( ( Fainting ( ( If yes, ______________

High Cholesterol ( ( Anxiety/Depression ( (

Do you bleed easily? ( ( Weakened Immune ( (

System (Transplant,

Leukemia, etc.)

List any other diseases or conditions: ____________________________________________________________________

__________________________________________________________________________________________________Hospitalizations or Surgical Procedures you have had: ______________________________________________________

Have you ever had a reaction to local anesthesia in a physician or dental office? ( Yes ( No If yes, ________________

Skin:

Have you ever had any form of skin cancer? ( Yes ( No If yes, __________________________________

Has anyone in your family had skin cancer? ( Yes ( No If yes, __________________________________

Have you ever had any form of cancer? (ex: lung) ( Yes ( No If yes, __________________________________

Do you have a history of any specific skin disease? ( Yes ( No If yes, __________________________________

Do you have problems with healing? ( Yes ( No

Do you develop keloids (scars) after surgery? ( Yes ( No

Do you develop skin rashes in reaction to: ( Bandages ( Neosporin

(Other _______________________________________________________________________________

Social History:

Do you drink alcohol? ( Yes ( No If yes, __________ drinks per day.

Do you use IV drugs? ( Yes ( No If yes, _______________________________________________

Smoking status ( Present ______packs per day ( Former ( Never

Do you have a history of: ( HIV ( Hepatitis ( STDs ( None

Are you pregnant, nursing or attempting to become pregnant? ( Yes ( No

What method do you use to prevent pregnancy? _________________________ N/A

Completed by: _____________________________________ Date: ____________________

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