Patient Intake Form

PATIENT INFORMATION:



Address





UNDER 18 years old?:

If child is 15 or older: Would you like to grant permission for them to be seen alone?

INSURANCE INFORMATION:

(Please give your insurance card to the receptionist.)










 

ACCOUNT PRIVACY


IN CASE OF EMERGENCY



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 [Name of Practice] or insurance company to release any information required to process my claims.

HEALTH HISTORY:

Past Medical History (please check all that apply):
  Anxiety
  Arthritis
  Asthma
  Atrial Fibrillation
  Bone Marrow Transplantation
  Breast Cancer
  Colon Cancer
  COPD
  Coronary Artery Disease
  Depression
  Diabetes
  End Stage Renal Disease
  GERD
  Hearing Loss
  Hepatitis
  High Blood Pressure
  HIV/AIDS
  High Cholesterol
  Thyroid Problems
  Leukemia
  Lung Cancer
  Lymphoma
  Prostate Cancer
  Radiation Treatment
  Seizures
  Stroke
  None
Have you had an influenza vaccine?:
Have you had a Pneumonia vaccine?:
Past Surgical History (please circle all that apply):
  Appendix Removed
  Bladder Removed
  Mastectomy (Right, Left, Bilateral)
  Lumpectomy (Right, Left, Bilateral)
  Breast Biopsy (Right, Left, Bilateral)
  Breast Reduction
  Breast Implants
  Colectomy: Colon Cancer Resection
  Colectomy: Diverticulitis
  Colectomy: IBD
  Gallbladder Removed
  Coronary Artery Bypass
  Mechanical Valve Replacement
  Biological Valve Replacement
  Heart Transplant
  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
  Kidney Transplant
  Ovaries Removed: Endometriosis
  Ovaries Removed: Cyst
  Ovaries Removed: Ovarian Cancer
  Prostate Removed: Prostate Cancer
  Prostate Biopsy
  TURP (prostate removal)
  Spleen Removed
  Testicles Removed (Right, Left, Bilateral)
  Hysterectomy: Fibroids
  Hysterectomy: Uterine Cancer
  None
Alerts (please check all that apply):
  Allergy to Adhesive
  Allergy to Lidocaine
  Allergy to Topical Antibiotics
  Artificial Heart Valve
  Artificial Joint Replacement
  Blood Thinners
  Defibrillator
  MRSA
  Pacemaker
  Require antibiotics prior to surgical procedure
  Rapid heartbeat with epinephrine
  Are you pregnant or currently trying to get pregnant?
  None
Skin Disease History (please check all that apply):
  Acne
  Actinic Keratoses
  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 Skin Cancer
  None
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):
Cigarette Smoking:
  Never Smoked
  Currently Smokes
  Has smoked in the past (socially)
  Former Smoker
Alcohol Use:
  NONE
  Less than 1 drink per day
  1-2 drinks per day
  3 or more drinks per day
Pharmacy Information



Natural Image OC

Notice of Privacy Policy

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

FINANCIAL POLICY

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.

Payment
  • 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.

Insurance
  • To protect against fraud you MUST present your insurance card at each visit, and we REQUIRE a government-issued ID onfile.
  • We will file claims to your insurance carrier and accept payment directly from them. It is the patient’s responsibility to keep us informed with up to date insurance coverage and contact information. Patients are fully responsible for all costs denied by their insurance.
  • It is your responsibility to know your insurance benefits. We can never guarantee insurance coverage for any service provided.
  • If your plan requires a referral or prior authorization to see the Doctor, it is your responsibility to obtain this prior to your visit.
  • MEDICARE PATIENTS: If you are currently covered under Medicare, please present ALL insurance cards at the time of your visit. Medicare offers a Medicare Advantage plan in lieu of traditional Medicare. If you have chosen an Advantage plan and do not present the correct card, you will be responsible for any denied charges.

  • *INITIAL HERE:
Labs
  • 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.

Collections
  • 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.

Patients Under 18 Years Old
  • 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.
FEES
  • Confirmation calls (made within 2 days of appointment) are considered a courtesy. We cannot be responsible for voicemails that are full and phone numbers that are disconnected. Patients are responsible for maintaining their appointment dates. To protect the practice, we must charge a “no show” fee for missed appointments. The fee is $50 for any missed appointments and appointments cancelled or rescheduled without a 24 hour notice. 
  • Returned check fee: You will be responsible for the full amount of any check returned from the bank for non-payment, in addition to a $35 check return fee.
  • A fee of $25 is assessed for printed medical records, medical letters for work, school, legal proceedings, health insurance, and paperwork for life insurance and disability applications.

By signing this form, I am stating that I have read the information above and understand my financial responsibility for my account.

 
Patient/Guardian signature

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Dr. Lenore Sikorski, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. 
 
 By checking this box, I acknowledge my understanding the HIPAA Policy and agree with its contents.





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