BURNSVILLE CENTENNIAL LAKES ORONO SARTELL MEDICAL CENTER MEDICAL CENTER PROFESSIONAL BUILDING OFFICE 14000 Nicollet Ave. So., #304 7373 France Ave. So., #304 2765 Kelley Parkway, #100 1350 LeSauk Drive Burnsville, MN 55337 Edina, MN 55435 Orono, MN 55356 Sartell, MN 56377 (952) 898-1600 (952) 224-5712 (952) 345-4222 (320) 252-7546 Dermatology and Cutaneous Surgery Dermatology Name _________________________________________________________________ Date _____/_____/_____ Medical Ethnicity ____________________________________________ DOB _____/_____/_____ History Primary Doctor/Clinic ___________________________________________ Referred by your doctor? Yes / No Reason for today’s visit ________________________________________________________________________________________ Do you have cosmetic concerns? Yes / No Circle: Botox, Radiesse, Juvederm, Sculptra, Veins, Hair removal, Wrinkles, Brown Spots Do you have any allergies? Yes / No If so, please list: _____________________________________________________________ Current Medications __________________________________________________________________________________________ Skin Conditions and Social History Yes No Past Surgeries Yes No Have you had skin cancer? □ □ Pacemaker / Defibrillator □ □ Basal Cell Carcinoma □ □ Joint replacement □ □ Squamous Cell Carcinoma? □ □ Heart valve replacement □ □ Melanoma skin cancer? □ □ Organ transplant □ □ Have you had abnormal / dysplastic moles? □ □ Tubal ligation □ □ Have you had pre-cancerous Actinic Keratosis? □ □ List other surgeries______________________________________ List any other skin conditions you have: (Examples: Eczema, Psoriasis, Acne, Rosacea, Vitiligo) Family Medical Problems Yes No ___________________________________________________ Skin cancer □ □ Do you use sunscreen? SPF _______ □ □ Melanoma □ □ Do you use tanning booths? □ □ Basal Cell □ □ Have you had blistering sunburns? □ □ Squamous Cell □ □ Do you heal with thick (keloid) scars? □ □ Abnormal moles □ □ Do you bleed / bruise easily? □ □ Eczema □ □ Do you react to numbing medications? □ □ Asthma □ □ Do you react to bandages or adhesive? □ □ Seasonal Allergies □ □ Do you need antibiotics for the dentist? □ □ Psoriasis □ □ Have you had staph infections / MRSA? □ □ Autoimmune diseases □ □ Do you smoke? # cigarettes/day _______ □ □ (Lupus, Rheumatoid arthritis, MS, Crohn’s, Colitis, Thyroid) Do you drink alcohol? drinks/day _______ □ □ Do you work outdoors? PMH: Circle your Medical Problems Occupation: ________________________________________ Cancer breast prostate ___________________ Hobbies: ___________________________________________ Immune HIV immune deficiency ROS: Circle any Symptoms you are having below Eye glaucoma cataract rosacea General weight loss fatigue Nose seasonal allergies chronic rhinitis Immune fever night sweats frequent infections Heart high blood pressure heart attack Eye dryness blurry vision irritation high cholesterol atrial fibrillation Heart chest pain ankle swelling palpitations heart valve problems clotting disorder Lungs shortness of breath cough Lungs COPD asthma tuberculosis GI nausea vomiting diarrhea GI acid reflux colitis irritable bowel Joint stiffness pain cramping Hepatitis B or C Neuro numbness tingling headaches weakness Joint arthritis joint replacement Endocrine heat/cold intolerance excessive thirst Brain stroke seizures migraine headaches Psych depression anxiety Endocrine thyroid diabetes polycystic ovary Heme easy bleeding bruising swollen nodes Psych depression anxiety attention deficit Skin itch burning redness discoloration scale OTHER _______________________________________________ Females pregnant nursing irregular periods Patient sign/date __________________________ ___/___/____ Planning pregnancy soon birth control pills Doctor sign/date ___________________________ ___/___/____
Transcript
BURNSVILLE CENTENNIAL LAKES ORONO SARTELL
MEDICAL CENTER MEDICAL CENTER PROFESSIONAL BUILDING OFFICE
Dermatology Name _________________________________________________________________ Date _____/_____/_____ Medical Ethnicity ____________________________________________ DOB _____/_____/_____ History Primary Doctor/Clinic ___________________________________________ Referred by your doctor? Yes / No
Reason for today’s visit ________________________________________________________________________________________
Do you have cosmetic concerns? Yes / No Circle: Botox, Radiesse, Juvederm, Sculptra, Veins, Hair removal, Wrinkles, Brown Spots
Do you have any allergies? Yes / No If so, please list: _____________________________________________________________
Current Medications __________________________________________________________________________________________
Skin Conditions and Social History Yes No Past Surgeries Yes No Have you had skin cancer? □ □ Pacemaker / Defibrillator □ □ Basal Cell Carcinoma □ □ Joint replacement □ □ Squamous Cell Carcinoma? □ □ Heart valve replacement □ □ Melanoma skin cancer? □ □ Organ transplant □ □ Have you had abnormal / dysplastic moles? □ □ Tubal ligation □ □ Have you had pre-cancerous Actinic Keratosis? □ □ List other surgeries______________________________________ List any other skin conditions you have:
(Examples: Eczema, Psoriasis, Acne, Rosacea, Vitiligo) Family Medical Problems Yes No ___________________________________________________ Skin cancer □ □ Do you use sunscreen? SPF _______ □ □ Melanoma □ □ Do you use tanning booths? □ □ Basal Cell □ □ Have you had blistering sunburns? □ □ Squamous Cell □ □ Do you heal with thick (keloid) scars? □ □ Abnormal moles □ □ Do you bleed / bruise easily? □ □ Eczema □ □ Do you react to numbing medications? □ □ Asthma □ □ Do you react to bandages or adhesive? □ □ Seasonal Allergies □ □ Do you need antibiotics for the dentist? □ □ Psoriasis □ □ Have you had staph infections / MRSA? □ □ Autoimmune diseases □ □ Do you smoke? # cigarettes/day _______ □ □ (Lupus, Rheumatoid arthritis, MS, Crohn’s, Colitis, Thyroid) Do you drink alcohol? drinks/day _______ □ □
Do you work outdoors? PMH: Circle your Medical Problems Occupation: ________________________________________ Cancer breast prostate ___________________ Hobbies: ___________________________________________ Immune HIV immune deficiency
ROS: Circle any Symptoms you are having below Eye glaucoma cataract rosacea General weight loss fatigue Nose seasonal allergies chronic rhinitis Immune fever night sweats frequent infections Heart high blood pressure heart attack Eye dryness blurry vision irritation high cholesterol atrial fibrillation Heart chest pain ankle swelling palpitations heart valve problems clotting disorder Lungs shortness of breath cough Lungs COPD asthma tuberculosis GI nausea vomiting diarrhea GI acid reflux colitis irritable bowel Joint stiffness pain cramping Hepatitis B or C Neuro numbness tingling headaches weakness Joint arthritis joint replacement Endocrine heat/cold intolerance excessive thirst Brain stroke seizures migraine headaches Psych depression anxiety Endocrine thyroid diabetes polycystic ovary Heme easy bleeding bruising swollen nodes Psych depression anxiety attention deficit Skin itch burning redness discoloration scale OTHER _______________________________________________
Females pregnant nursing irregular periods Patient sign/date __________________________ ___/___/____ Planning pregnancy soon birth control pills Doctor sign/date ___________________________ ___/___/____
SKIN CARE DOCTOR’S, P.A. PATIENT REGISTRATION Patient Name (First, Middle, Last)
Patient’s Birthdate
/ /
Parent/Guardian, if under age 18
Guardian Birthdate
/ /
Street Address
Home Phone
( ) -
City
State Zip Code Work Phone
( ) -
Patient Social Security Number
- -
Marital Status □ Single □ Married □ Widow □ Separated □ Divorced
Cell Phone
( ) -
Male or Female M F
Patient’s Occupation If Student Full-time Part-time
E-mail Address
Employer’s Name
Employer’s Address
SPOUSE INFORMATION
Spouse’s Name (First, Middle, Last)
Spouse’s Birthdate
/ /
Spouse’s Employer
Spouse’s Work Phone
( ) -
INSURANCE INFORMATION
Primary Insurance
ID # Group
Policy Holder
Policy Holder’s Birthdate / /
Secondary Insurance
ID # Group
Policy Holder
Policy Holder’s Birthdate / /
IF PATIENT IS A MINOR OR COVERED UNDER PARENT’S INSURANCE, PLEASE FILL OUT BELOW
Father’ Name (First, Middle, Last)
Father’s Birthdate
/ /
Father’s Employer
Father’s Address
Father’s Home Phone Number
( ) -
Father’s Work Phone Number
( ) -
Mother’s Name (First, Middle, Last)
Mother’s Birthdate
/ /
Mother’s Employer
Mother’s Address Mother’s Home Phone Number
( ) -
Mother’s Work Phone Number
( ) -
EMERGENCY INFORMATION - Person to notify in case of emergency other than household member.
Name (First, Middle, Last)
Relationship Home Phone Number
( ) -
Work Phone Number
( ) -
Street Address
City State Zip Code
REFERRAL
Referred by (Physician, Yellow Pages, Other)
Clinic Telephone Number
( ) -
Treatment Authorization: I hereby authorize Skin Care Doctors, P.A. to treat my / the patient’s condition as they deem appropriate.
Assignment of Benefits: I hereby assign the authorized benefits and direct that payment under any insurance or health benefits plan be made directly to Skin Care Doctors, P.A. for any services rendered to me or on my behalf.
Medicare Patients: I request that payment of authorized Medicare Benefits be made either to me or on my behalf to Skin Care Doctors, P.A. for any services furnished me by that organization. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine those benefits or the benefits payable for related services.
Records Release to Insurance Carriers and Other Payors: I hereby authorize Skin Care Doctors, P.A. to release to my insurance company, health plan, HMO or Workers’ Comp carrier, any information including my complete health record needed to determine benefits for service provided by or on behalf of Skin Care Doctors, P.A.
I understand that I am financially responsible for charges not covered under my insurance policy.
Patient/ Guardian Signature __________________________________________________________ Today’s Date _______/_______/_______ Staff Use Only: Received By _____________________ Entered By ________________________ Date Entered _______/_______/_______
Authorization to Disclose Protected Health Information Patient’s Name_____________________________ DOB: ____________
Your privacy is important to us and we want to protect it as much as possible. By signing this form, you authorize Skin Care Doctors, P.A to disclose information as requested by the individual(s) you list below. This information may include, but is not limited to, verbal and written information relating to your diagnosis, treatment, and billing information. Please complete, sign, and date this form. Be sure to include any individuals and/or specific details you may have listed previously, if appropriate, as any prior versions of this form will be inactive upon receipt of this completed form.
Is it okay to leave normal laboratory or pathology results on your answering machine to the phone numbers we have on file? Cell number Yes ______ No _______ Home number Yes ______ No _______ Work number Yes ______ No _______
Is it okay to leave a detailed voice message regarding your care on your answering machine to the phone numbers we have on file? Cell number Yes ______ No _______ Home number Yes ______ No _______ Work number Yes ______ No _______
Write the name of the person(s) to receive information:
*If you want to limit the information disclosed, specify here: ________________________________________________ 2) __________________________________________________ Relationship to patient: �Parent(s) �Spouse �Child(ren) � Sibling(s) �Other_____________________________
*If you want to limit the information disclosed, specify here: _________________________________________________
This authorization may be revoked at any time except to the extent that This authorization is valid until the following Skin Care Doctors, PA has taken action in reliance upon this authorization. Specified date or event, whichever is shorter. Revocation must be made in writing to Skin Care Doctors, PA, attn.: Privacy Officer at 14000 Nicollet Ave So, Suite 304, Burnsville, MN 55337. Specified Date (MM, DD, YYYY)
I understand that Skin Care Doctors, PA will not condition treatment, payment, enrollment, __________________________________ or eligibility for benefits on whether I sign this authorization. I also understand that I may be charged for copies of this information in accordance with state law.
Futhermore, I understand that if this information is disclosed to a third party, the information Specified Event may be redisclosed by the person that receives the information and may no longer be protected by federal privacy regulations. ___________________________________
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form. *If the patient is 18 years of age or older, the patient must sign and date the form. *If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form. Please indicate your legal authority and include documentation of your relationship. �Legal guardian or Conservator �Healthcare Agent (Healthcare Power of Attorney) *If the patient is 17 years of age or younger, the patient’s parent or legal guardian must sign and date the form (unless an exception exists under state or federal law. Please indicate your relationship: �Parent �Legal Guardian
Signature (Required) Date Signed (Required) MM, DD, YYYY
Printed Name of Person Signing (if NOT patient) Staff Signature
SKIN CARE DOCTORS, P.A.
Dermatology and Cutaneous Surgeiy
DE
PROCE
The Insurance industry states: "A y time a layer of skin is destroyed by the p ysician or the physician goes within the realm of the body, the procedure is considered surgical."
Examples of such procedures include: Freezing with liquid nitrogen, scraping, excision, shave, topical application of chemicals (i.e., DNCB, Canthacur) and injectable medications. If you have further questions about the description, please ask your physician or you may want to contact your insurance company.
This procedure may have a deductible or co-insurance that you will be responsible for paying depending upon the contractual coverage you have with your insurance company. Our office is informing you of this, as there are too
any contracts for our office to know how your particular contract reads. It is your responsibility to know your benefits under your insurance coverage. Our aim is to better inform you.
If you understand and concur with the above information, we ask that you sign your consent of understanding that we have informed you of these potential procedures and your financial responsibility.
Welcome and thank you for choosing Skin Care Doctors, PA for your dermatology care. It is a pleasure to serve you. We are
committed to providing the best dermatologic care possible. Your clear understanding of our Patient Financial Policy is
important to our professional relationship. Carefully review the following information and return this form with your
signature and today’s date. Please ask if you have any questions about our fees, our policies, and/or your responsibilities.
Registration/Check-in: At the time of registration, and periodically thereafter, you will be asked to complete a Registration
Form to help keep personal and insurance information accurate. You will be asked to present a photo ID and current insurance card when you check in for each appointment. Any past due balance will be collected at the time of check-in. Patients under the age of 18 must have a parent or legal guardian in attendance at their first appointment.
Insurance – Skin Care Doctors, PA participates with most major health insurance plans. Insurance plans vary in the amount of
coverage and medical services provided. It is your responsibility to check with your insurance company to confirm Skin Care
Doctors, PA is within your network and your medical services will be covered. If your plan requires that you have a referral
prior to seeing our dermatologists, please contact your primary care physician so that you have the referral at the time of your
appointment. Patients that are unable to provide proof of coverage or do not have health insurance will be required to pay for
the services the day of the appointment.
You are responsible for knowing your insurance benefit coverage. Skin Care Doctors, P.A. specializes in Dermatological care
so your medical services are considered medically necessary or Cosmetic but never preventative. Preventative care is
provided by your Primary Care Provider or Specialty providers who render service that your Primary Care Provider cannot
render (example: Colonoscopy or Mammogram). We will gladly file your insurance claim on your behalf to the companies
with which we participate. We allow 45 days for your insurance company to process the claim. If the insurance company does
not process your claim within that time, you will be responsible to pay the entire amount. We will not become involved in
disputes between you and your insurance company regarding coverage and/or policy benefit criteria such as deductibles, co-
pays, co-insurance, non-covered services, and coordination of benefits. You are responsible for all co-payments and
deductibles at the time of service. We accept cash, personal checks, money orders, MasterCard and Visa.
Cosmetic Services: Cosmetic services are not covered by insurance or HSA/HRA/Flex/Bene plans. When scheduling a cosmetic
appointment, a $100 deposit will be collected to reserve the appointment. This deposit is then applied to the amount charged
for the cosmetic treatment with the balance due at the time services are rendered. A 24-hour cancellation notice is required
and failure to do so will result in the loss of the $100 deposit.
Returned Checks: If a check is returned as unpaid by your bank, a $35 returned check charge will be applied and we will no
longer accept checks as a form of payment.
Collections: Please contact us if you have trouble paying your bill. Accounts with an outstanding balance over 60 days past due
that have failed to make payment arrangements will be turned over to a collection agency. If your account is turned over to a
collection agency, all non-emergent appointments will be cancelled until the collection account has been paid. Once paid, you
may schedule appointments at our office, but your account will be on a cash-only basis for one year allowing time to re-
establish credit worthiness. During this time, payment is required at the time of the appointment. As a courtesy, we will
forward a claim to your insurance company. We will issue a refund to you if/when they pay on your claim.
Printed Name of Patient or Parent if patient is a minor Signature of Patient or Parent if patient is a minor Date
