New Patient Registration

DOB: 
Age:
Sex:  F
 
Marital Status:   
Race:   
Address:
Street:
City:  
State:
Zip:
Phone:
 Daytime:
 Work:
 Cell:
Employer:
Email:

Read Private Policy Here

YES! I would like to receive emails and monthtly newsletters regarding promotions and packages from The Center for Plastic Surgery at MetroDerm.
Referring Physician:
Phone#:
City:  
State:
Zip:
Primary Care Physician:
Phone#:
City:  
State:
Zip:
Pharmacy:
Phone#:
Emergency Contact:
Relationship:
Phone#:

Insurance Policy Holder Information:

Policy Holder:
DOB: 
Relationship:
Street:
City:  
State:
Zip:
Primary Insurance Company:
Subscriber ID:
Group#:
Secondary Insurance Company:

I hereby consent to treatment of myself, my child or above-named minor for whom I accept responsibility; and the release of medical information to any insurance carrier and/or direct payment to MetroDerm, P.C. for any authorized treatment or examination rendered. I hereby acknowledge and accept final responsibility for payment or charges for medical services rendered.

Date:

History and Intake

Reason for today's visit: 

Skin Type (Check I, II, III, IV, V, VI)

Allergies

Medications (Including vitamins and over the counters)

Medication Dosage (mg, ml, %, strength, etc) What medication is used for

Surgical History

Surgery Date What was the surgery for?

As of Today's Visit

At today's visit, do you have any of the following?

 Fevers or chills   Yes  
  Coughs
 Changing Moles
Crusting or Bleeding spots
Easy Bruising
Hives
New Growths on skin
Problems with bleeding
Problems with healing
 Problems with scarring
 Rash
 Skin Pigmentation Changes
 Abdominal Pain
 Anxiety
 Hay Fever
 Headaches
 Immunosuppression
Joint Aches 
Muscle Weakness 
 Palpitations
 Urinary frequency/urgency

Do you have any of the following?

Allergy to adhesive 
 Allergy to latex
 Allergy to lidocaine
 Allergy to topical antibiotic ointment
 Artificial heart valve
 Artificial joints (Within last two years)
 Take blood thinners
Pacemaker/Defibrillator 
 HIV
 Hepatitis
 Vasovagal response to procedures

If you checked yes for anything, are you currently undergoing treatment?

Explain: 

Are there any symptoms that you think we should be aware of, or pertain to today's visit? 

Personal History

Have you ever smoked?  

Do you drink alcohol?  

Do you currently smoke?  
Packs Per day: 

# of drinks a week 

Have you had any skin cancers: If so, what type(s): 

Have you had any sunburns?  

How many? 

Do you use sunscreen?  

Where did you grow up? 

Have you formed excessive or unsatisfactory scars/keloids in the past?  

 Family History

( Information about immediate family members. If Yes , Please list the family member in the space provided)

 Heart Disease:    Diabetes:  
 Stroke:    Cancer:  
 Anesthesia Reaction:    Bleeding Disorder:  
Skin cancers:     If so, what type(s): 

HIPAA CONSENT FORM

Patient Name: 
 

Consent for Release of Medical and Financial Information to Authorized Individual(s)

 

  Name: 
  Phone Number: 
 Relationship:
  Name: 
  Phone Number: 
  Relationship: 

In the event we are unable to reach you or your authorized individual(s), may we leave a detailed message with your results on an answering machine or voice mail at the above-listed telephone number?

Ok to receive an email?

Ok to receive text messages?

Permission to import medications from the pharmacy:

Consent to Photograph

MetroDerm, PC may choose to take medical photographs of me to be part of my medical record for purposes of comparison before and after certain treatments, to track certain types of lesions, or for medical teaching and publications. I agree that photographs may be taken during the procedure and these photographs remain the property of MetroDerm, PC.

Initialed by Patient (or Parent/Guardian, if patients is a Minor)

Patients 65 and Older (only fill out this section for patients age 65 or older)

Have you received your pneumonia vaccination? 

Do you have a health care proxy in the event you are unable to make your own medical decisions?

If yes: Designee's name:

Phone number:

Do you have a living will?

Which statement best reflects your wishes on advanced care recommendations? 

 

 

Patient Signature: 
Date:

Financial Policy

1. FINANCIAL AGREEMENT I hereby assume full responsibility for all charges incurred for professional service rendered by MetroDerm, P.C., unless the service is deemed "paid in full" as a result of a contractual agreement between MetroDerm, P.C., and my insurer. I understand Metroderm can only provide general information regarding provider participation in my specific plan and that it is up to me to verify participation, referral requirements, and benefit details with my insurance carrier prior to my appointment. I understand that MetroDerm can NEVER guarantee coverage for any service provided due to the fact that insurance companies will not guarantee benefits until they receive claim for said services; therefore, If you are unsure of your coverage benefits, you should call the customer service number on your insurance card.

2. AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize MetroDerm, P.C., to release any medical, psychiatric, infectious disease (including AIDS confidential information) or drug and/or alcohol related information to my referring physician and any insurance company with whom I have medical benefits for the purpose of filing a medical claim. I acknowledge that this authorization is valid until such time as all medical bills related to my treatment have been paid. I further understand that I can withdraw this consent for release of information at any time prior to this expiration date except to the extent that this action has been taken in reliance hereon.

3. GROUP & INDIVIDUAL INSURANCE, ASSIGNMENT OF BENEFITS I authorize my health insurance benefit plan to pay directly to MetroDerm, P .C., the surgical and/or medical benefits. If any, otherwise payable to me for their services as described on attached claim but not to exceed the changes for those services. I understand I am financial responsible to MetroDerm, P.C., for charges not covered by this agreement.

4. MEDICARE, CLAIM AUTHORIZATION, AND PAYMENT REQUEST I authorize any holder of medical or other information about me to release to the Social Security Administration and Healthcare Financing Administration for its intermediaries or carrier any information needed for this or a related claim. I permit a copy of this authorization to be used in place of the original, and request of medical insurance benefits to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

  • All applicable co-pays, deductibles, and prior balances are due at the time of service.
  • We accept cash, checks, and all major credit cards.
  • We DO NOT accept checks for cosmetic procedures or cosmetic products.

5. Regarding Insurance We participate with Medicare and most insurance plans. However, you must realize that your insurance is a contract between you, the insurance company, and/or your employer. While we may be a provider of services, we are not a party to the contract. It is imperative that complete personal information and a copy of your current insurance card is provided prior to being seen to ensure accurate billing. PLEASE NOTE: If incorrect insurance information is given by the patient or patients guarantor, any denial or unpaid claim will be the financial responsibility of the patient.

Some insurance companies arbitrarily select certain services they will not cover or which they may consider medically unnecessary. In these instances, you will be responsible for these amounts. Some Policies have deductibles for surgical procedures. The insurance companies consider procedures like cryosurgery (freezing with liquid nitrogen), removal of moles, or other small procedures as "surgery". If you have a surgical deductible that has not been met and have one of these procedures, you will be responsible for payment at the time of service. Please be aware that any amount collected from you at the time of service is just an estimate. Final patient responsibility is determined by your insurance carrier and you will be billed for any responsibility left to you by your insurance carrier less any payments made by you towards your visit.

6. Missed Appointments Please help us to serve you better by keeping scheduled appointments. Appointments must be canceled at least 24 hours in advance. Please be aware that if you no-show for your appointment, or cancel your appointment within 24 hours of your scheduled appointment, you will be charged a $50.00 fee.

7. PAYMENT DUE Be advised that we require payment in full within 90 days of the receipt of the explanation of benefits from your insurance company. Our practice does understand that medical bills at time can be burdensome. If you need more than 90 days to pay your balance you must contact our office to make a payment arrangement. You will be required to provide a credit/debit card that can be auto-drafted each month to secure payment. Any balance past 90 days due without a secured payment arrangement on file will be considered overdue and will be subject to collections. Please be advised that recurring payment arrangements are subject to approval and the length of duration is dependent on the amount owed. The maximum duration for any balance may not exceed 12 months.

8. Past Due Accounts Overdue accounts will be turned over to a collection agency. Please be aware that a $50.00 processing/filing fee, as well as a fee of 40% of your balance, will be added to your account. EXAMPLE: $200 owed + $50 processing + $80 (40%) = $330 will be your new account balance

Returned Checks

-For checks returned to us as unpaid by your bank, we will charge a $45 fee.

I have read the Financial Policy. I understand and agree to the Financial Policy: