Past Surgical History (please circle all that apply):
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Colectomy: Colon Cancer Resection
Coronary Artery Bypass
Mechanical Valve Replacement
Biological Valve Replacement
Joint Replacement, Knee (Right,Left, Bilateral)
Joint Replacement, Hip (Right,Left, Bilateral)
Joint Replacement, within last 2 years
Kidney Biopsy (Nephrectomy)
Kidney Removed (Right, Left)
Kidney Stone Removal
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
TURP (prostate removal)
Testicles Removed (Right, Left, Bilateral)
Hysterectomy: Uterine Cancer
Alerts (please check all that apply):
Allergy to Adhesive
Allergy to Lidocaine
Allergy to Topical Antibiotics
Artificial Heart Valve
Artificial Joint Replacement
Require antibiotics prior to surgical procedure
Rapid heartbeat with epinephrine
Are you pregnant or currently trying to get pregnant?
Skin Disease History (please check all that apply):
Basal Cell Skin Cancer
Flaking or Itchy Scalp
Hay Fever/ Allergies
Squamous Cell Skin Cancer
Do you wear sunscreen?:
Do you tan in a tanning salon?:
Family Medical History (immediate relatives ONLY):
Do you have a Family History of Melanoma?:
Medications (list current medication. if none, put N/A):
Allergies (incl. food, & seasonal. if none, put N/A):
Social History (please mark all that apply):
Has smoked in the past (socially)
Less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
Natural Image OC
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
As our patient, you have entrusted your medical information to our care. We know that your relationship with us is based on trust, and that you expect us to act in your best interest. As your personal medical history is your private information, we hold ourselves to the highest standards in its safekeeping.
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. HIPAA provides penalties for covered entities that misuse personal health information. We are required by law to maintain the privacy of your protected healthcare information and to provide you with this notice of our legal duties and our privacy practices. HIPAA gives you, the patient the right to understand and control how your protected health information (“PHI”) is used.
Under HIPAA regulations, we may use and disclose your Protected Health Information (PHI) without written consent for treatment, payment and health care operations (TPO).
- Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this is communicating with your referring physician, pharmacy or laboratory.
- Payment means activities related to obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include verifying insurance coverage or sending you a billing statement.
- Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. Examples of this would be patient survey cards or contacting you by phone or in writing to remind you of an appointment.
- We may also be required or permitted to disclose your PHI for law enforcement, matters of public health and safety, and other legitimate reasons. In all situations, we shall do our best to assure its continued confidentiality to the extent possible.
We will not use your information for marketing or fundraising without your permission.
In compliance with federal and state privacy laws, written authorization by the patient or legal guardian is required before we can release records for reasons other than treatment, payment and healthcare operations.
If you give authorization to release your records, you may revoke such authorization in writing, and we will honor your request from the date we receive your written request forward.
Protecting Your Privacy Online
Our concern for your privacy naturally extends to our online communication. We transfer your data over the Internet to submit health insurance claims and send electronic prescriptions to your pharmacy via a secure server. We will file an insurance claim to your private insurance, Medicare or Supplement if you authorize us to do so. If you request us not to give details about services to an insurance company, such as cosmetic services, we will make every effort to honor your request.
You may have the following rights with respect to your PHI:
You have the right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you.
- You can advise us of the best location to contact you to protect your private information.
- You can request a copy of medical record in writing.
- You can request an amendment of your PHI. This request must be done in writing and will be honored at our discretion.
- We keep a log of disclosures of your medical information for the past six years and you can request a copy
- We will notify you if a breach of your protected health information if it occurs.
Please let us know if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with our practice and with the Department of Health and Human Services, Office of Civil Rights.
Patient Acknowledgement Receipt of Privacy Notice
- I, hereby affirm that I have received a copy of the Notice of Privacy Practices from Natural Image OC Under federal law 104-191, also known as HIPAA, I am entitled to receive a copy of this Notice from my healthcare provider.
- I understand that my signature on this Acknowledgement only signifies that I have received a copy of the Notice, and does not legally bind or obligate me in any way.
- I understand that I am entitled to receive a copy of the Notice of Privacy Practices from my healthcare provider, whether I sign this Acknowledgement or not.
Signature of Patient or Representative
Welcome and thank you for choosing our practice. Our goal is to provide excellent care and superior patient service. Our policies are printed below. Your agreement to follow these policies will help us serve you.
- Our office accepts cash, personal checks, debit cards, Visa, MasterCard, American Express, and Discover.
- If your insurance cannot be verified at the time of your visit, you may reschedule or be a Self-Pay patient.
- Co-payments and account balances are due at the time ofservice.
- Co-insurance (deductible) Plans: If your insurance plan does not require copayment and your deductible or out-of-pocket has not been met, you may receive a bill for your office visit.
- Partial payment may be required when scheduling cosmetic procedures
- Self-Pay Office Visit: New patients - $175 Established patients - $100. Procedures are an additional cost quoted by theDoctor.
- Refunds: Our office does not issue refunds for services rendered or products (incl. in-office prescriptions) purchased. You can return the product to the office, and the amount may/will be credited to your account.
- Lab tests ordered through our office are billed separately to your insurance from the laboratory. Patients are responsible for any lab charges.
- If your insurance requires that tests be sent to a specific lab, it is your responsibility to tell the Nurse, not the front desk, at the time the test is ordered.
Patients Under 18 Years Old
- Balances are due within 30 days of statement date.
- Past due balances: Outstanding balances are sent to a collections agency and your account with our practice may beclosed.
- The patient registration form must be signed and guaranteed by the legal guardian accompanying the minor at the first appointment. The “Responsible Party” is legally responsible for payment.
By signing this form, I am stating that I have read the information above and understand my financial responsibility for my account.