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PO Box 691 Murrells Inlet, SC 29576
P: (843) 651-4600 F: (843) 651-4601
www.seaside-dermatology.com
-Live your life, just do it with sunblock
NEW PATIENT PAPERWORK
Full Name :________________________________ Social Security
Number: ________-______-_________ Date of Birth
:_______________________________ Gender: _________________________
Address: ____________________________________
____________________________________________
Primary Phone: (____) ________-_________________Work Phone:
(____) ________-___________________Mobile Phone: (____)
______-____________________OK to leave detailed messages by phone?
Yes___No___
____________________________________________
Email Adress (required):
___________________________________________ Emergency Contact Name:
________________________________________________
Emergency Contact Phone: (____)
________-___________________________ Pharmacy Name and
City:_____________________________________________________________________
Employment:_______________________________________________________________________________
Providers: Primary Care Physician: ____________________________
Phone (required): (____) ________-_____________
Referring Physician: _______________________________ Phone
(required): (____) ________-_____________
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-Live your life, just do it with sunblock
Allergies & Medications
Are you currently or have you ever been a smoker?
Have you received a pneumonia vaccine this year? Y N If yes,
when?_____________
Pregnant or actively trying to get pregnant? Y N Weight :
_______ Height:________
Y N Start smoking date: _______________ Quit smoking date:
_______________
Number of packs per day: __________ Total number of years a
smoker:_____
Social History
Medication Allergies Reaction
Example:Penicillin Rash Medication Dosage Frequency
Example: Aspirin 81 mg Daily
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Cancellation Policy No Show/Late Cancellation Policy
Patient Consent for Use and Disclosure of Protected Health
Information
Photo Consent
Cosmetic Appointment Policy
-Live your life, just do it with sunblock
In an effort to ensure all patients receive care in a fair and
timely manner, effective October 1, 2015, Seaside Dermatology, PA
will charge a No Show/Late Cancellation fee of $100.00 for patients
who do not show for their appointments or who cancel their
appointment less than 24 hours notice. Providing advanced notice is
not only a courtesy but provides an opportunity for another patient
in need to be seen. The cancellation/missed appointment fees are
the sole responsibility of the patient and are not covered by
insurance. Seaside Dermatology understands that special unavoidable
circumstances may cause you to cancel within 24 hours. Fees in this
instance may be waived but only with management approval.Payment of
any outstanding missed appointment/cancellation fees will be
required for scheduling future appointments.
Effective December 1, 2018, Seaside Dermatology requests $50.00
deposit to create cosmetic appointments regarding Neurotoxin or
Filler appointments and the deposit will be applied towards goods
rendered at service date. If no goods are selected at service date,
the deposit fee will be returned back via check. You agree to
forfeit if you fail to show or notify Seaside Dermatology, PA that
a reschedule is needed 24 hours prior to appointment.
I give consent for medical photographs to be made of me or my
child (or the person whom I am legal guardian). I understand that
the photos will become a part of my medical record and will be used
for medical record purposes only.
Our Notice of Privacy Practices provides information about how
Seaside Dermatology may use and disclose protected health
Information (PHI) about you to carry out treatment, payment, and
healthcare operations. You have the right to review our Notice of
Privacy Practices prior to signing this consent. Seaside
Dermatology reserves the right to revise its Notice of Privacy
Practices at any time. If we change our Notice, you may obtain a
revised copy by contacting our office or by obtaining directly from
our website at www.seaside-dermatology.com.
By signing this form, you consent to our use and disclosure of
protected health information (PHI). You have the right to revoke
this consent, in writing, signed by you. However, such a revocation
shall not affect any disclosures we have already made in reliance
on your prior consent. Seaside Dermatology provides this form to
comply with the Health Insurance Portability and Accountability Act
of 1996 (HIPPA)
PATIENT/GUARDIAN SIGNATURE DATE
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Patient Financial Agreement
PLEASE READ THOROUGHLY AND SIGN BELOW. In consideration of
receiving services from a Seaside Dermatology facility, you agree:
1. All services are provided to you with the understanding that you
are responsible for the cost regardless of your insurance coverage.
If you would like to know the cost of a service, please inquire
prior to treatment. Please be aware that not all services are a
covered benefit with different insurance companies. You are
responsible for knowing what services are or are not covered. KNOW
YOUR BENEFITS. 2. On the date of service, we will collect your
deductible, co-pay, and payment for any uncovered services as well
as the patient’s portion as determined by insurance. 3. Your
insurance policy is a contract between you, your employer, and the
insurance company. We are NOT a party to that contract. It is your
responsibility to notify this office immediately if your insurance
coverage or company changes. It is your responsibility to
understand your coverage and benefits, including
pre-certifications, referral and authorization requirements, and to
be sure all insurance information is current. 4. We will bill your
insurance company as a courtesy but you are still ultimately
responsible for payment of all services you receive. If your
insurance company does not respond we will follow up with an
inquiry on your behalf. If, however, your insurance does not
respond again, a statement will be sent to you. You should call
your insurance to question why the claim is not paid. Our office
will be happy to assist after you have contacted your insurance. 5.
If your medical claim has not processed and your insurance company
has not resolved your dispute, you may register a complaint with
the South Carolina Department of Insurance. Our office will do
everything we can to assist you, however you must understand you
cannot delay payment while you are awaiting the outcome of your
complaint. 6. Any unpaid charges over 90 days old will be
considered for an outside collection agency. You are responsible
for any collection fees, legal fees, or court costs incurred in the
collections process. This agency will report your failure to pay to
the THREE (3) national credit reporting agencies. 7. Non-Insured:
If you do not have medical insurance, you will be responsible for
payment at the time of service for the service to be received that
day, as well as any previous outstanding balance. If a procedure is
necessary, payment may be required prior to the procedure. 8.
Seaside
Dermatology
caps
patient
balances
at
$250.
While
we
expect
all
accounts
to
be current, we do realize the financial hardships that medical
bills can carry. Should you need to be seen at our facility, your
will be required to pay your balance down to at least $250 before a
visit takes place.
9. You will be assessed a $20 service fee on
all returned checks due to insufficient funds in addition to the
amount of the actual check. If your account becomes delinquent, the
guarantor is responsible for any collection fees, interest, or
attorney fees. 10. Non-Covered Services: Some services we provide
may be deemed not medically necessary by your insurance carrier or
not a covered benefit by your specific policy, therefore not paid
by your insurance. Many cosmetic procedures we provide are not
covered by insurance. The patient is responsible for payment at the
time of service for all services not covered by insurance. 11.
Collection Agency Policy: You are financially responsible for
services in the office. Furthermore, any account balance that is
not paid may be sent to a collection agency. Should any delinquent
account balance be referred to a collection agency, you will be
financially responsible for any and all costs and fees relating to
the collection of your debt. If an account is sent to a collection
agency, an additional fee (45% collection fee/interest) will be
added to the ending balance of the account sent to the agency. 11.
Laboratories: If your insurance company requires a specific
laboratory, it is your responsibility to notify us. Otherwise, we
will send your specimen to a cooperating laboratory. If there are
any costs related to the biopsy, pathology, cultures, or other lab
work that your insurance carrier does not cover you will be
responsible for those costs. 12. If you are enrolled in a Managed
Care Insurance Plan (HMO) it is YOUR responsibility to obtain or
ensure that a referral and/or authorization is supplied to our
office from your primary care physician prior to the time of your
appointment. We commonly schedule routine follow up exams as a
courtesy to you upon checking out. Unfortunately, these future
appointments may be outside of authorization extension allowance
and require new authorization that our office is unable to complete
on your behalf. 13. We are committed to providing you with the best
possible care, and we are willing to discuss our professional fees
at any time. Your clear understanding of our Financial Policy is
important to our relationship. Please ask if you have any questions
about our fees, Financial Policy, or your financial responsibility.
PATIENT/GUARDIAN SIGNATURE DATE
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HIPAA: Private Information Release Authorization
I, , hereby authorize Seaside Dermatology, P.A. to discuss with
the following people information concerning my health treatment,
billing, insurance information, and appointments.
Spouse Name: PHONE:
Parent / Legal Guardian: Name: PHONE:
Significant Other Name: PHONE:
Any Specified Person Name: PHONE:
Restrictions:
No Restrictions
Do not discuss any information regarding my health including
appointment time, test/lab/pathology results, pre and post surgery
instructions, billing/insurance, or account information with anyone
except me.
Only discuss my appointment time with the above named
individual(s).
Only discuss my test/lab/pathology results with the above named
individual(s).
Only discuss my pre and/or post surgery instructions with the
above named individual(s).
Only discuss issues concerning my account, including insurance,
and/or billing with the above named individual(s).
MESSAGES MAY BE LEFT ON MY ANSWERING MACHINE/VOICEMAIL REGARDING
THE ABOVE
Yes
No
I understand I may terminate this consent at any time by giving
written notice to Seaside Dermatology, P.A.. Any changes to this
form will require a new consent form to be completed, signed, and
dated.
Signature: ____________________________________________________
Date: ________________
Printed Name:
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Name:________________________ Phone : (______)
__________-_____________
Name:________________________ Phone : (______)
__________-_____________
Name:________________________ Phone : (______)
__________-_____________
Name:________________________ Phone : (______)
__________-_____________
Messages may be left on my answering machine/voicemail regarding
the above
Restrictions:
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