Dermatology Associates of Ithaca Patient Registration

NEW PATIENT REGISTRATION

MEDICAL HISTORY
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Sex *

M F
Primary Care Provider:
Preferred Pharmacy:
Please describe the reason for this consultation: *
Were you referred by another physician? *

YES NO
By whom? *
Have you ever experienced any medication allergies or sensitivities (inc. skin sensitivies to topical medications or bandages)? *

YES NO
Please describe which medication(s) and the reaction you experienced: *
For example, “Penicillin – Hives”
Have you ever had any reaction to numbing medication (such as at the dentist)? *

YES NO
Please describe your reaction to numbing medication: *
MEDICATIONS - Please enter all current medications, include OTC, vitamins and herbals:
(If none, enter "NONE" on first row)
Allergies: (Please enter all allergies)
Have you ever been diagnosed with skin cancer? *

Yes No
Please tell us as many details about it as you know, including what type of skin cancer, where on your body, how/when it was treated, and by whom: *
Have you been diagnosed with any skin condition(s)?

Yes No
Please describe which skin condition(s), how treated, etc.:
Past Medical History:

Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation Breast Cancer Colon Cancer Congestive Heart Failure COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood pressure High Cholesterol HIV/AIDS Hyperthyroid Hypothyroid Leukemia Lung Cancer Lymphoma Radiation Treatment Seizures Stroke
Past Medical History:

Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation Colon Cancer Congestive Heart Failure COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood pressure High Cholesterol HIV/AIDS Hyperthyroid Hypothyroid Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke
Past Medical History:

ADD/ADHD Anxiety Anemia or bleeding problem Asthma Bone Marrow Transplantation Depression Diabetes Heart problems/murmur Hearing Loss HIV/AIDS Leukemia Problems with hearing Seizures Thyroid or other gland problem
I don't have any significant history of illness or medical conditions
Do you have an advance care directive ("living will")? *

Yes No
Which of the following describes your wishes? *

Full Code - I would like full life saving measures Do not Intubate - I would like life saving measures without the use of a breathing tube Do not Resuscitate - I do not want any life saving measures including cardiopulmonary resuscitation
Do you have a health care proxy? *

Yes No
Health Care Proxy's Name: *
Health Care Proxy's Phone Number: *
Have you received an influenza (flu) vaccine this year? *

Yes No
Why? *
Have you received a pneumonia vaccine? *

Yes No
Have you ever had surgery? *

Yes No
Past Surgical History: *

Appendix Removed Biological Valve Replacement Bladder Removed Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Coronary Artery Bypass Gallbladder Removed Heart Transplant Joint Replacement, Hip (Right, Left, Bil) Joint Replacement, Knee (Right, Left, Bil) Kidney Stone Removal Kidney Transplant Mechanical Valve Replacement Prostate Biopsy Prostate Removed: Prostate Cancer Spleen Removed Testicles Removed (Right, Left, Bilateral) TURP (Prostate Removal)
Past Surgical History: *

Appendix Removed Biological Valve Replacement Bladder Removed Breast Biopsy (Right, Left, Bilateral) Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Coronary Artery Bypass Gallbladder Removed Heart Transplant Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Joint Replacement, Hip (Right, Left, Bil) Joint Replacement, Knee (Right, Left, Bil) Kidney Stone Removal Kidney Transplant Lumpectomy (Right, Left, Bilateral) Mastectomy (Right, Left, Bilateral) Mechanical Valve Replacement Ovaries Removed: Cyst Ovaries Removed: Endometriosis Ovaries Removed: Ovarian Cancer Spleen Removed
Skin Disease History:

Acne Actinic Keratosis Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Cancer
Please check if you have any of the following:

PACEMAKER/DEFIBRILLATOR ARTIFICIAL HEART VALVE HEART MURMUR ARTIFICIAL JOINT
Have you been advised to take antibiotics prior to any dental/surgical procedures? *

YES NO
Have you ever had major surgery?

YES NO
Please list:
Do you have any other medical history that we should know about? *

YES NO
PLEASE DESCRIBE: *
Do you wear Sunscreen?

Yes No
What SPF?
Do you tan in a tanning salon?

Yes No
Do you have a family history of Melanoma?

Yes No
Which relative(s)?
Social History:

Current everyday smoker Current Someday smoker Quit: Former smoker Never smoker
Alcohol Use:

EtOH-None EtOH-1 or less drink per day EtOH-1-2 drinks per day EtOH-3 or more drinks per day
Review of Systems: Are you currently experiencing any of the following? (Please check yes or no)

SYMPTOM

	Yes	No
Problems with bleeding?
Problems with healing?
Problems with scarring?
New or changing pigmented lesions?
Immunosuppression?
Problems with rashes?

Other Symptoms:
Alerts

Allergy to Adhesive Allergy to lidocaine Allergy to topical antibiotics Are you pregnant or currently trying to get pregnant? Artificial heart valve Artificial joint replacement Blood thinners Defibrillator/Pacemaker
WOMEN:
Are you pregnant? *

YES NO
Breastfeeding? *

YES NO
Trying to become pregnant? *

YES NO
Have your parents, siblings or children been diagnosed with melanoma? Please note that it's specifically a family history of "melanoma" which is important (not "basal cell" nor "squamous cell" carcinoma). *

YES NO
Who? *
PLEASE INDICATE IF YOU...
SMOKE? *

YES NO
For how many years? *
How long does it take for you to finish a pack? *
DRINK ALCOHOL *

YES NO
How many drinks/how often? *
USE “RECREATIONAL” OR IV DRUGS? *

YES NO
Please list *
USE TANNING BEDS REGULARLY? *

YES NO
How often? *
WEAR SUNBLOCK REGULARLY? *

YES NO

INSURANCE/RELEASES
What is your Primary Insurance? *
Please upload photos (FRONT/BACK) of your insurance card(s) AS WELL AS pictures of your photo ID (FRONT/BACK). We cannot file your insurance claim without BOTH of these:

UPLOAD PHOTO(S)

Cancel of
IN CASE OF EMERGENCY
Parent/Guardian *
Name of Emergency Contact *
Relationship to Patient *
Home Phone # *
Other Phone #
PROTECTED HEALTH INFORMATION RELEASE
Do you allow the staff of Dermatology Associates of Ithaca to speak to anyone else regarding matters of your health (including lab results and appointments)? *

Yes No
Do you allow the staff of Dermatology Associates of Ithaca to speak to anyone else regarding matters of your child's health (including lab results and appointments)? *

Yes No
Name *
Relationship *
Name
Relationship
Do you allow the staff of Dermatology Associates of Ithaca to leave voicemail messages regarding your care? *

Yes No
Do you allow the staff of Dermatology Associates of Ithaca to leave voicemail messages regarding your child's care? *

Yes No
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dermatology Associates of Ithaca or insurance company to release any information required to process my claims.
Name of Parent/Legal Representative *
Signature of Patient/Legal Representative *

Clear
Signature of Parent/Legal Representative *

Clear
Date *

Month Day Year
Date
If you have an email address that you would like for us to use to communicate with you, please provide it here:
example@example.com

GENERAL CONSENT
*
*
Signature of Parent/Legal Representative *

Clear
Signature of Patient *

Clear
Date *

Month Day Year
Date
HIPAA COMPLIANCE STATEMENT - THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

At Dermatology Associates of Ithaca we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION - Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care.

YOUR RIGHTS - Although your medical chart belongs to our practice, the information contained in the chart is yours. You have the right to inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information.

OUR RESPONSIBILITIES - We are required to maintain the privacy of your health information, send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission.

EXAMPLES OF HOW YOUR INFORMATION IS USED - Your health information will be recorded and used to plan your treatment. Reports may be sent to other doctors to help them plan your treatment. Bills will be sent to your insurance company. The information in the bills will include confidential information such as your name, address, diagnosis, and treatment. In providing your care, we may communicate with other individuals or businesses. Examples include other physicians and/or laboratories. To protect your privacy, we ask our business associates to safeguard your information.

OTHER NOTICES - We may leave a message at your home, at your business, on your answering machine or on your voicemail. We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation
insurance company. We may, from time to time, update these policies.

FOR MORE INFORMATION OR TO REPORT A PROBLEM - If you have concerns or would like additional information, you may contact the practice’s Privacy Officer at (607) 257-1107.
Signature *

Clear
Signature of Parent/Legal Representative *

Clear
Date *

Month Day Year
Date

PAYMENTS POLICIES
1. Insurance. We participate with most major insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full may be required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payment and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your copayment/deductible at each visit. If you are unable to pay at the time of service, your appointment may be rescheduled.

3. Non-covered services. Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered medically necessary by Medicare or other insurers. You must pay for these services in full at the time of your visit.

4. Proof of insurance. All patients must complete our patient information forms before seeing the provider. We must obtain a copy of a current valid insurance card 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.

5. Claims submission. We will submit your claims and assist you in any reasonable way we can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. 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.

6. Insurance changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. Divorce. In case of divorce or separation, the party responsible for payment on the account is the parent authorizing treatment for a child. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent. We do not forward bills to other parties regardless of court rulings or divorce decrees.

8. Returned Checks. There is a $25 fee for any check returned by the bank.

9. Non-payment. If your account is over 90 days past due, we may refer your account to a collection agency and report it to the credit bureau.

10. No Show/Cancellations. If you must cancel or reschedule an appointment, we ask that you call as soon as you can, preferably at least 48 hours before your scheduled appointment time. Failing to show up for your appointment or cancelling less than 24 hours in advance (unless extenuating circumstances) are both documented and subject to a cancellation fee ($30 for consultations/$50 for surgical appointments). After three "no shows," or "late cancellations" our policy is to discharge the patient from the practice.

I have read and understand the payment policy and agree to abide by its guidelines.
Printed Name
Signature

Clear
Signature of Parent/Legal Representative

Clear
Date

Month Day Year
Date

Should be Empty:

NEW PATIENT REGISTRATION