Fillable Patient Registration Form

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Patient Registration Form

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The Patient Registration Form form is 7 pages long and contains:

  • 6 signatures
  • 63 check-boxes
  • 163 other fields

Country of origin: OTHERS
File type: PDF

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Patient Registration Form
Please complete all the information below in print, please do not leave any questions blank. Thank You!
Sign (Patient or Guardian) _____________________________________________ Date: _______________________
Ad
d
ress: _____________________ City: _________________ State: ____ Zip: _______
Name: _______________________
P
hone: _______________
Fax:
________________
PR
EFERRED PHARMACY:
Race: _____________ Ethnicity: _____________ Email Address: ________________________________________
Gender: _____________ Marital Status: _____________ SSN: _________________ Language: ______________
Home Ph: ______________________ Work Ph: ______________________ Mobile Ph: ______________________
Address: _____________________________________________ City: _________________ State: ____ Zip: _______
Last Name: __________________ First Name: __________________ Middle: ____________ Date of Birth: _________
PATIENT INFORMATION:
Home Ph: _____________________ Mobile Ph: ______________________
Name: ________________________________________ Relationship: ______________________
EMERGENCY CONTACT:
PolicyHolder:__________________________Relationship: ____________________________DOB: _______________
Address: _____________________________________________ City: _________________ State: ____ Zip: _______
Name: ____________________ Policy No: ____________ Group No: ___________ Phone: ______________________
PRIMARY INSURANCE INFORMATION:
PolicyHolder:_________________________Relationship: _____________________________DOB: _______________
Address: _____________________________________________ City: _________________ State: ____ Zip: _______
Name: ____________________ Policy No: ____________ Group No: ___________ Phone: ______________________
SECONDARY INSURANCE INFORMATION:
Name: ___________________________
___
____ Address: ______________
__________________________
__Phone:
____________________________
REFERRING PROVIDER:
Name: _____________________________
___
__ Address: __
_______________________________________
_Phone
:___________
_________________
PRIMARY CARE PROVIDER:
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signature
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Medical History Form
Please complete all the information below in print and check all that applies, please do not leave any questions blank. Thank You!
MEDICAL HISTORY: Check any of the following that you currently have
Anxiety
COPD
Hepatitis
Prostate Cancer
Asthma
Atrial Fibrillation
Coronary Artery
Disease
Hypertension
HIV/AIDS
Radiation
Treatment
Bone Marrow
Transplant
Depression
Diabetes
Hyperthyroidism
Hypothyroidism
Seizure
None
BPH
Breast Cancer
End Stage Renal
Disease
Leukemia
Lung Cancer
Other
Hearing Loss
Lymphoma
Have you had a Flu Vaccine this flu season (October – March 31
st
)? YES / NO
PAST SURGICAL HISTORY: Have you had any of the following surgeries? None
Organ Transplant: Organ:___________ Year_____
Joint Replacement: Joint ___________ Year_____
SKIN DISEASE HISTORY: Have you had any of the following?
Acne
Actinic Keratosis
Basal Cell Carcinoma
Yr: ______ Location: _______
Yr: ______ Location: _______
Yr: ______ Location: _______
Dry Skin
Eczema
Flaking or Itchy Scalp
Melanoma
Yr: _____ Location: ________
Yr: _____ Location: ________
Atypical/Dysplastic Moles
Psoriasis
Squamous Cell Carcinoma Yr:
_
0 ___ Location: ________ Yr:
_____ Location: ________
Yr: _____ Location:
________
Do you wear sunscreen? YES / NO If yes, what SPF? _____________ Have you tanned in a salon? YES / NO
Do you have a FAMILY history of Melanoma? YES / NO If yes, which relative?_______________________________
MEDICATIONS: please list all (or attach)
ALLERGIES TO MEDICATIONS: please list all
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
SOCIAL HISTORY:
Smoking Status (Please choose one):
Alcohol Intake (please choose one):
Current, every day smoker
None
Current, occasional smoker
1 or less per day
Former smoker
1-2 per day
Never smoked
3 or more per day
Sign (Patient or Guardian) _____________________________________________ Date: _______________________
W
eight:
Height:
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signature
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Financial Policy
Thank you for choosing Vivida Dermatology as your healthcare provider! Our mission is to provide exceptional care and state of the
art treatment to every patient, every appointment, every day. Please read this document in full, initial at each line, and sign in the
space below. A copy can be provided to you upon request.
_____Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we are contracted with,
payment in full is expected at each visit. If you do not have your card and/or we are unable to verify your eligibility and benefits,
payment in full is expected at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurance
company with any questions you may have regarding your coverage.
_____Co-payments, Deductibles, and Coinsurances. All co-payments and deductibles must be paid at the time of service. This
arrangement is part of our contract with your insurance company and is mandatory. Failure to pay for the estimated fees at the time
of service, then your appointment may be rescheduled. Every effort is made to collect accurate payment at the time services are
rendered. This is, however, only an ESTIMATE of benefits. Actual benefits are determined and based by the terms and conditions of
your insurance plan or policy. If your insurance adjudicates your claims differently, our office will adhere to the policies set forth by
your insurance. Occasionally, this could result in the need for additional payment.
_____Proof of Insurance/Coverage changes. All patients must complete our patient information form before seeing the provider.
We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with
the correct insurance information in a timely manner, you may be responsible for the balance of a claim. We will verify eligibility and
benefits copay, coinsurance, and deductible amounts prior to your appointment as a courtesy, so it is imperative that you provide any
updated insurance or personal information.
_____Cash Pay Patients. Every effort is made to collect accurate payment at the time services are rendered. However, the totals
provided upon check-out are only an ESTIMATE of the cost of services rendered in our office, and self-pay patients may be subject to
receiving an itemized bill after the date of service. All estimated payments for services rendered must be paid at the time of service.
Failure to not pay for the estimated fees at the time of service will result to rescheduling your appointment.
_____Claims submission. We will submit your claims as a courtesy. If your claim is denied, we will assist you in any way we reasonably
can to help get responsible payment to comply with their requests. Please be aware that the balance of your claim is your responsibility
whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance
company; we are not party to that contract. Please be aware that some—and perhaps all—of the services you receive may be non-
covered or not considered reasonable or necessary by Medicare or other insurers. You must pay in full for these services at the time
of visit.
_____Nonpayment. If your account is over 45 days past due, you will receive a call or email stating that you have 14 days to pay your
account in full. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. If your account
is assigned to a collection agency, you agree to pay all expenses we may incur in collecting the delinquent balance.
_____Missed Appointments. If you fail to show for a scheduled appointment and do not cancel or reschedule at least 24 hours in
advance, you may be charged a $25.00 “No Show Fee”.
_____Medical Records/FMLA. For all FMLA paperwork, there is a $50.00 fee. However, this does not guarantee the FMLA paperwork
will ensure your time off will be approved, as the majority of our services do not require an extended amount of time away from work.
For all general medical records requests, there is a $.60/page fee to be charged at 5 or more pages.
I have read and understand the payment policy and agree to abide by its guidelines:
Patient Name _______________________________________________________ DOB: _________________________
Sign (Patient or Guardian) _____________________________________________ Date: _________________________
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Terms of Services
Please initial:
______ I authorize Vivida Dermatology to send any specimen obtained through the course of my treatment to an outside lab. These
labs analyses are separate services from those received in this office and will be billed separately by the lab. Vivida Dermatology will
make every effort to send specimens to labs within the insurance network, however, it is my responsibility to inform Vivida
Dermatology of the lab that is contracted with my insurance. I understand that I will be billed separately from both Vivida Dermatology
(for the service of obtaining any specimen) and the lab (for the analysis of said specimen).
______ I authorize Vivida Dermatology to receive, mail, fax, and/or e-mail my records to another physician or medical facility in the
course of my diagnosis and treatment.
______ I will present my most current insurance card(s) and photo ID when I check in for each appointment.
______ I understand that it is my responsibility to notify Vivida Dermatology of any changes to my information including, but not
limited to: mailing address, phone number(s), insurance policies, or any other information that Vivida Dermatology needs to be able
to contact me, collect payment, and/or otherwise carry out my treatment.
______ I authorize Vivida Dermatology to access my pharmaceutical records and history.
______ I acknowledge that it is my responsibility to understand my insurance policy and benefits. I am responsible for ensuring that
the provider I am receiving services from is contracted (in-network) with my insurance. It is my responsibility to obtain a referral
and/or prior-authorization/precertification if required by my insurance. Failure to understand my policy, benefits, network, and/or
insurance requirements will not relieve me of my financial responsibility to Vivida Dermatology. Vivida Dermatology will make every
effort to understand and explain my benefits, confirm the provider is contracted with my insurance, obtain any necessary referrals
and/or prior authorization/precertification, and satisfy all insurance requirements for service. However, I acknowledge that is my
responsibility to ensure that everything is satisfied correctly and I will not hold Vivida Dermatology liable for any failure on my part.
______ I authorize Vivida Dermatology, and their agents, to contact me by any method that I provide contact information for including:
telephone calls (landline and wireless), voicemails/voice messages, text messages, emails, and mail. I understand that if I do not want
Vivida Dermatology, or their agents to contact me in a certain way, then I will not provide the applicable telephone/wireless cellphone
number, email address, or mailing address. If I provide any contact information, then I expressly consent my authorization for Vivida
Dermatology, and their agents, to contact me by these means.
I have read and understand the terms of services and agree to abide by its guidelines:
Patient Name _______________________________________________________ DOB: _________________________
Sign (Patient or Guardian) _____________________________________________ Date: _________________________
If this does not pertain to you, please skip.
Treatment to Minors (Under 18yrs old)
Patient Name: Date of birth: / /
Dear Parents/Guardians, this form has been prepared for your convenience should you at some time be
unable to accompany your minor child to their medical appointment.
I hereby grant to accompany my minor child
when they arrive at the office for their medical appointment.
/ /
Signature of Parent Date
Quality Measures (65yrs old and over)
Date: ____________________________
Patient Name: _______________________________________Date of Birth: / /
Vaccination Status
Have you received a Pneumonia vaccination? Yes / No
Advance Care Planning
Do you have a healthcare proxy in the event you are unable to make your medical decisions? Yes / No
Designee’s Name ______________________________________________
Designee’s Phone Number _______________________________________
Do you have a living will? Yes / No
Please initial next to one of the statements that best reflects your wishes on advanced care:
______ Do not Intubate: I do not wish to have a breathing tube, even if it is necessary to save my life.
______ Do not resuscitate: If my heart were to stop, I do not wish to have chest compressions or an
automated external defibrillator to restart my heart, even if it’s necessary to save my life.
______ Full Cardiopulmonary Resuscitation (CPR): I want full cardiopulmonary resuscitation efforts to be
made.
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HIPAA NOTICE of PRIVACY PRACTICES
At Vivida Dermatology, we are committed to treating and using protected health information about you responsibly. This notice of Health
Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your
rights as they relate to your protected health information. This notice is effective, and applies to all protected health information as defined by federal
regulations.
Understanding Your Health Record/Information
Each time you visit Vivida Dermatology, a record of your visit is made. Typically, this record contains your symptoms, examination and test results,
diagnoses, treatment, and a plan for the future care or treatment. This information, often referred to as your health or medical record, serves as a:
- Basis for planning your care and treatment,
- Means of communication among the many health professionals who contribute to your care,
- Legal document describing the care you received,
- Means by which you or a third-party payer can verify that services billed were actually provided,
- A tool in educating health professionals,
- A source of data for medical research,
- A source of information for public health officials charged with improving the health of this state and the nation,
- A source of data for our planning and marketing,
- A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when,
where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your health record is the physical property of Vivida Dermatology, the information belongs to you. You have the right to:
- Obtain a paper copy of this notice of information practices upon request.
- Inspect and copy your health record.
- Amend your health record.
- Obtain an accounting of disclosures of your health information.
- Request communications of your health information by alternative means or at alternative locations.
- Request a restriction on certain uses and disclosures of your information.
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Our Responsibilities
Vivida Dermatology is required to:
- Maintain the privacy of your health information,
- Provide you with the notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,
- Abide by the terms of this notice
- Notify you if we are unable to agree to a requested restriction, and
- Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our
information practices change, we will mail a revised notice to the address you have supplied us.
We will not use or disclose your health information without your authorization, except as described in this notice. We will discontinue using or
disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the
authorization.
For More Information or to Report a Problem
If you have questions and would like additional information, you may contact the practice’s Privacy Officer, Michael Borenstein at 702-255-6647. If
you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer or with the Office for Civil Rights,
U.S. Department of Health and Human services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for
Civil Rights. The address for the OCR is: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Ave. S.W.,
Room 509F, HHH Building, Washington, D.C. 20201.
Acknowledgement of Receipt of Privacy Notice
I hereby acknowledge that a copy of the “Notice of Privacy Practices” is available for my review, and I may receive a copy upon request.
Sign Date Print Name
Please allow access to my Protected Health Information (PHI) which includes billing and medical records to my (circle as many as apply):
Spouse Child Parent Guardian Other
Name Date Relationship
Patient Signature Date Print Name
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Fax Number: _______________________
Phone Number: _______________________
Address:
_______________________________________________________________
Facility Name: ________________________________________________________________
Personal
Primary Care Physician
Legal Representation
Other
I hereby authorize Vivida Dermatology to
RECEIVE
copies of my medical records from:
__________________________________________________________________________________________
Patient Signature: ______________________________________________________________________
has no control
over the use of the previously released copies.
I
understand that once my medical records have been released, Vivida Dermatology cannot retrieve them and
that this authorization may be revoked at any time by giving oral or written notice to Vivida Dermatology
I understand that this information shall be in effect following the date of the signature. However, Iunderstand
Phone Number: _______________________
Treatment dates (if applicable):
___________
to ___________
Patient Name: _______________________________________
Date of Birth:
______________________
Date of Request: ____________________________________
Authorization to Release Protected Health Information
Ph: (702)
255-6647 Fax: (702) 933-1444
Las Vegas, NV 89148
6460 Medical Center St.,
Suite 200 &
350
Fax Number: _______________________ Phone Number: _______________________
Address: _______________________________________________________________
Facility Name: ________________________________________________________________
Other ______________
Pathology Reports
Progress Notes
Operative Reports
Photos
Entire Medical Record
I hereby authorize Vivida Dermatology to
RELEASE
copies of my medical records
to:
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Patient Registration Form

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Completed 1 May 2021

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