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PATIENT INFORMATION
Appointment Date: _____________________ Time: _____________ with Dr. ________________
Last Name______________________________________________First Name____________________________________ M.I.___________ Mailing Address _____________________________________________________________________________________________________ Street Address________________________________________________________________________________________________________ City____________________________________________________________________State__________________Zip___________________ Sex: M / F
Marital Status: (circle one)
M S W D
Spouse’s Name___________________________________________________
Social Sec. #_______________________________________________ Date Of Birth________________________________Age___________ Home Phone#_______________________________Work Phone #____________________________ Cell _____________________________ Referred By: (Please Circle One)
Family member
Doctor
Friend
Yellow pages
Newspaper Ad
Referring Doctor:________________________________________________ Phone # _____________________________________________ PCP (Primary Care Physician): ____________________________________ Phone # _____________________________________________ Your Employer__________________________________________________ Phone # _____________________________________________ Pharmacy: ______________________________________________ Pharmacy Telephone Number: ________________________________ Emergency Contact : ________________________________________________________ Phone Number: ___________________________ Name
Relationship
*******************************************************************************************************************************************************************************
PRIMARY INSURANCE: (patients without current insurance card at time of service will be considered self-pay unless cards received within 30 days) Insurance Company: __________________________________________________________________________________________________ Ins. ID/ Member #: _________________________________________ Group #/ Name: ___________________________________________ Subscriber Name: __________________________________________ Subscriber’s Date of Birth: __________________________________ Subscriber’s Relationship to Patient: ____________________________________________________________________________________ Subscriber’s Address:_________________________________________________________________________________________________ City________________________________________________________________State_____________________Zip____________________ Home Phone: _______________________________ Work Phone: ________________________________ SS# ________________________ Employer: __________________________________________________________________________________________________________ *******************************************************************************************************************************************************************************
SECONDARY INSURANCE: Insurance Company: __________________________________________________________________________________________________ Ins. ID/ Member #: _________________________________________ Group #/ Name: ___________________________________________ Subscriber Name: __________________________________________ Subscriber’s Date of Birth: __________________________________ Address: ______________________________________________________ City/ST _____________________________________________ Home Phone: _______________________________ Work Phone: ________________________________ SS# ________________________ Employer: __________________________________________________________________________________________________________ *******************************************************************************************************************************************************************************
HIPAA INFORMATION:
A copy of our privacy policy will be provided to you at your appointment.
I have been notified of the Skin Cancer and Dermatology Center of Colorado Springs, P.C. privacy policy. ___________________________________________________ Patient Signature
____________________________________________ Date
PATIENT HISTORY NAME:
APPT. DATE:
Where is your problem? When did you first get the skin problem? Where did it first start? Has it been there all the time since then?
NO
YES
Have you ever had the same skin problem before?
NO
YES
Have you ever had a different skin problem in the past?
NO
YES
PLEASE DRAW ON THIS CHART WHERE YOUR PRESENT SKIN PROBLEM OR RASH IS BY SHADING IN.
NOTES
MEDICINES: MEDS: Has your doctor given you anything for the skin?………….…..
NO
YES Please give names of all substances used.
Have you put anything else on the skin yourself?…….….……
NO
YES Please give names of all substances used.
Are you taking any pills, medicines, tablets or drugs regularly?
NO
YES What? Please give exact names.
Cortisone drugs…………...……………………………..…………..
NO
YES
Aspirin or pain killers……………………….………………………..
NO
YES
"Nerve Pills" sedatives or tranquilizers……………..……………..
NO
YES
Laxatives (for constipation)……………………………………….
NO
YES
Contraceptive pills………………………………………………….
NO
YES
Blood Thinners……………………………………………………
NO
YES
Have you had any bad reactions to any drugs?………………
NO
YES
Do you take any of the following tablets or medicines?
Which ones? (OVER)
GENERAL (SOCIAL HISTORY)
What is your present work or occupation? What types of work have you done in the past? Do you have any special hobbies?
NO
YES
Do you take part in any sports? (e.g. swimming)
NO
YES
Do you smoke tobacco?
NO
YES
Do you drink alcohol?
NO
YES
Do you have any pets?
NO
YES
Have you traveled abroad over the last two years?
NO
YES
Have you ever traveled or lived outside the USA?
NO
YES
RELATIVES AND FAMILY Do any of your relatives or family have the following illnesses?
Which relatives? Please write the disease.
Hay fever, eczema or asthma (wheezy chest)
NO
YES
Psoriasis
NO
YES
Any other skin problems Diabetes or T.B. Does any member of the family or friend have the same skin problem as yours?
NO NO
YES YES
NO
YES
Are you under MEDICAL treatment now? If so, for what?
NO
YES
Have you ever had any SURGERY?
NO
YES
PAST HISTORY
If so, what? When?
DO YOU OR HAVE YOU EVER HAD:
Heart Trouble/Rheumatic Fever High Blood Pressure Pacemaker Frequent or Severe headache Epilepsy/Stroke Bleeding Problems Fingers turn colors when cold Arthritis Difficulty Swallowing Shortness of Breath Chest Pain Keloids or Abnormal Scars Eczema Hay Fever/Sinus Asthma Sinus Infection Ear Infection Kidney or Bladder Trouble
NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO
YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES
Fever Blisters/Cold Sores Tuberculosis Bad Teeth Cough Recent Nausea or Vomiting Recent Diarrhea Recent Indigestion Loss of Appetite Swollen Glands Weight Loss Diabetes Thyroid Condition Hepatitis/Liver Disease Stomach Ulcers Cancer Are you Pregnant?
NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO
YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES
Brett K. Matheson, M.D. Christopher R. Sartori, M.D.
History Reviewed By
Date
595 Chapel Hills Drive, Suite 303 Colorado Springs, CO 80920 Phone (719) 574-0310
SKIN CANCER & DERMATOLOGY CENTER OF COLORADO SPRINGS, P.C. 595 Chapel Hills Drive, Suite 303, Colorado Springs, CO 80920 FINANCIAL POLICY AND PATIENT AGREEMENT The following is the financial policy of the Practice, which we require that you read, and sign prior to treatment: In order to establish optimal relations with our patients and avoid misunderstanding regarding our payment policies, our staff is trained to inform you of the financial policies of this office. PAYMENT IS EXPECTED FROM YOU, AT THE TIME OF SERVICE, FOR “YOUR PART” OF THE CHARGES. WE ACCEPT CASH, CHECK, VISA, AND MASTERCARD, DISCOVER, AND AMERICAN EXPRESS FOR YOUR CONVENIENCE. Insurance: The patient must recognize that he/she is responsible to pay the full amount for all services unless the Practice has an agreement with the patients’ insurance carrier for alternative payments. As a courtesy to patients, the Practice will file insurance claims with all standard insurance carriers. The patient is responsible to make available to the Practice complete insurance information, for accurate filing of claims. Insurance information includes referrals from other providers for primary and secondary insurance coverage, all identification and benefits cards/documents. The patient agrees that if the insurance company denies benefits for any reason, that the patient is responsible for the full amount of the bill immediately. The practice’s policy on accepting insurance payments varies based on the type of insurance as follows: INDEMNITY-TYPE INSURANCE – insurance payments received by the Practice will be applied to the patient’s account and the patient agrees to pay the balance. Co-Payments are due at the time of service and are collected before service is provided. HMO’s and PPO’s – If the Practice has an agreement with the patient’s insurance carrier, we will accept payment from the carrier for services covered by the patient’s benefit plan. Co-Payments are due at the time of service and are collected before service is provided. For services not covered by the patient’s benefit plan, payment is due at the time of service. MEDICARE—The practice accepts assignment from Medicare. Therefore, the patient agrees to pay the Practice the Medicare coinsurance PLUS any amount of the patient’s deductible that is not yet paid and any service not covered by Medicare. Regulations pertaining to Medicare assignment of benefits apply. By this agreement, the patient also authorizes the exchange of information relating to care and claims with the patient’s insurance company(s), its intermediaries, carriers, and referring physician and authorizes insurance payments to be made directly to the Physician for services provided under the patient’s insurance agreement and otherwise payable to the patient. The patient understands that delinquent accounts are subject to finance charges and collection fees, and that special financial arrangements can only be made with an addendum to this document. PATIENT AGREEMENT: stated.
I have read and understand the financial policy above and agree to the terms
_____________________________________ ______________________________________ Patient’s Signature/Guardian
Date
MEDIGAP: If you have a supplemental policy and it is a MEDIGAP policy to which your Medicare Carrier automatically “crosses over”, we are required to keep a separate signature on file: I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize the Practice to release to my MEDIGAP carrier any information needed to determine benefits or the benefits payable for related services.
_____________________________________ ______________________________________ Signature as it appears on Medigap Card
Date
Appointment Date: _____________________ Time: _____________ with Dr. ________________
Last Name______________________________________________First Name____________________________________ M.I.___________ Mailing Address _____________________________________________________________________________________________________ Street Address________________________________________________________________________________________________________ City____________________________________________________________________State__________________Zip___________________ Sex: M / F
Marital Status: (circle one)
M S W D
Spouse’s Name___________________________________________________
Social Sec. #_______________________________________________ Date Of Birth________________________________Age___________ Home Phone#_______________________________Work Phone #____________________________ Cell _____________________________ Referred By: (Please Circle One)
Family member
Doctor
Friend
Yellow pages
Newspaper Ad
Referring Doctor:________________________________________________ Phone # _____________________________________________ PCP (Primary Care Physician): ____________________________________ Phone # _____________________________________________ Your Employer__________________________________________________ Phone # _____________________________________________ Pharmacy: ______________________________________________ Pharmacy Telephone Number: ________________________________ Emergency Contact : ________________________________________________________ Phone Number: ___________________________ Name
Relationship
*******************************************************************************************************************************************************************************
PRIMARY INSURANCE: (patients without current insurance card at time of service will be considered self-pay unless cards received within 30 days) Insurance Company: __________________________________________________________________________________________________ Ins. ID/ Member #: _________________________________________ Group #/ Name: ___________________________________________ Subscriber Name: __________________________________________ Subscriber’s Date of Birth: __________________________________ Subscriber’s Relationship to Patient: ____________________________________________________________________________________ Subscriber’s Address:_________________________________________________________________________________________________ City________________________________________________________________State_____________________Zip____________________ Home Phone: _______________________________ Work Phone: ________________________________ SS# ________________________ Employer: __________________________________________________________________________________________________________ *******************************************************************************************************************************************************************************
SECONDARY INSURANCE: Insurance Company: __________________________________________________________________________________________________ Ins. ID/ Member #: _________________________________________ Group #/ Name: ___________________________________________ Subscriber Name: __________________________________________ Subscriber’s Date of Birth: __________________________________ Address: ______________________________________________________ City/ST _____________________________________________ Home Phone: _______________________________ Work Phone: ________________________________ SS# ________________________ Employer: __________________________________________________________________________________________________________ *******************************************************************************************************************************************************************************
HIPAA INFORMATION:
A copy of our privacy policy will be provided to you at your appointment.
I have been notified of the Skin Cancer and Dermatology Center of Colorado Springs, P.C. privacy policy. ___________________________________________________ Patient Signature
____________________________________________ Date
PATIENT HISTORY NAME:
APPT. DATE:
Where is your problem? When did you first get the skin problem? Where did it first start? Has it been there all the time since then?
NO
YES
Have you ever had the same skin problem before?
NO
YES
Have you ever had a different skin problem in the past?
NO
YES
PLEASE DRAW ON THIS CHART WHERE YOUR PRESENT SKIN PROBLEM OR RASH IS BY SHADING IN.
NOTES
MEDICINES: MEDS: Has your doctor given you anything for the skin?………….…..
NO
YES Please give names of all substances used.
Have you put anything else on the skin yourself?…….….……
NO
YES Please give names of all substances used.
Are you taking any pills, medicines, tablets or drugs regularly?
NO
YES What? Please give exact names.
Cortisone drugs…………...……………………………..…………..
NO
YES
Aspirin or pain killers……………………….………………………..
NO
YES
"Nerve Pills" sedatives or tranquilizers……………..……………..
NO
YES
Laxatives (for constipation)……………………………………….
NO
YES
Contraceptive pills………………………………………………….
NO
YES
Blood Thinners……………………………………………………
NO
YES
Have you had any bad reactions to any drugs?………………
NO
YES
Do you take any of the following tablets or medicines?
Which ones? (OVER)
GENERAL (SOCIAL HISTORY)
What is your present work or occupation? What types of work have you done in the past? Do you have any special hobbies?
NO
YES
Do you take part in any sports? (e.g. swimming)
NO
YES
Do you smoke tobacco?
NO
YES
Do you drink alcohol?
NO
YES
Do you have any pets?
NO
YES
Have you traveled abroad over the last two years?
NO
YES
Have you ever traveled or lived outside the USA?
NO
YES
RELATIVES AND FAMILY Do any of your relatives or family have the following illnesses?
Which relatives? Please write the disease.
Hay fever, eczema or asthma (wheezy chest)
NO
YES
Psoriasis
NO
YES
Any other skin problems Diabetes or T.B. Does any member of the family or friend have the same skin problem as yours?
NO NO
YES YES
NO
YES
Are you under MEDICAL treatment now? If so, for what?
NO
YES
Have you ever had any SURGERY?
NO
YES
PAST HISTORY
If so, what? When?
DO YOU OR HAVE YOU EVER HAD:
Heart Trouble/Rheumatic Fever High Blood Pressure Pacemaker Frequent or Severe headache Epilepsy/Stroke Bleeding Problems Fingers turn colors when cold Arthritis Difficulty Swallowing Shortness of Breath Chest Pain Keloids or Abnormal Scars Eczema Hay Fever/Sinus Asthma Sinus Infection Ear Infection Kidney or Bladder Trouble
NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO
YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES
Fever Blisters/Cold Sores Tuberculosis Bad Teeth Cough Recent Nausea or Vomiting Recent Diarrhea Recent Indigestion Loss of Appetite Swollen Glands Weight Loss Diabetes Thyroid Condition Hepatitis/Liver Disease Stomach Ulcers Cancer Are you Pregnant?
NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO
YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES
Brett K. Matheson, M.D. Christopher R. Sartori, M.D.
History Reviewed By
Date
595 Chapel Hills Drive, Suite 303 Colorado Springs, CO 80920 Phone (719) 574-0310
SKIN CANCER & DERMATOLOGY CENTER OF COLORADO SPRINGS, P.C. 595 Chapel Hills Drive, Suite 303, Colorado Springs, CO 80920 FINANCIAL POLICY AND PATIENT AGREEMENT The following is the financial policy of the Practice, which we require that you read, and sign prior to treatment: In order to establish optimal relations with our patients and avoid misunderstanding regarding our payment policies, our staff is trained to inform you of the financial policies of this office. PAYMENT IS EXPECTED FROM YOU, AT THE TIME OF SERVICE, FOR “YOUR PART” OF THE CHARGES. WE ACCEPT CASH, CHECK, VISA, AND MASTERCARD, DISCOVER, AND AMERICAN EXPRESS FOR YOUR CONVENIENCE. Insurance: The patient must recognize that he/she is responsible to pay the full amount for all services unless the Practice has an agreement with the patients’ insurance carrier for alternative payments. As a courtesy to patients, the Practice will file insurance claims with all standard insurance carriers. The patient is responsible to make available to the Practice complete insurance information, for accurate filing of claims. Insurance information includes referrals from other providers for primary and secondary insurance coverage, all identification and benefits cards/documents. The patient agrees that if the insurance company denies benefits for any reason, that the patient is responsible for the full amount of the bill immediately. The practice’s policy on accepting insurance payments varies based on the type of insurance as follows: INDEMNITY-TYPE INSURANCE – insurance payments received by the Practice will be applied to the patient’s account and the patient agrees to pay the balance. Co-Payments are due at the time of service and are collected before service is provided. HMO’s and PPO’s – If the Practice has an agreement with the patient’s insurance carrier, we will accept payment from the carrier for services covered by the patient’s benefit plan. Co-Payments are due at the time of service and are collected before service is provided. For services not covered by the patient’s benefit plan, payment is due at the time of service. MEDICARE—The practice accepts assignment from Medicare. Therefore, the patient agrees to pay the Practice the Medicare coinsurance PLUS any amount of the patient’s deductible that is not yet paid and any service not covered by Medicare. Regulations pertaining to Medicare assignment of benefits apply. By this agreement, the patient also authorizes the exchange of information relating to care and claims with the patient’s insurance company(s), its intermediaries, carriers, and referring physician and authorizes insurance payments to be made directly to the Physician for services provided under the patient’s insurance agreement and otherwise payable to the patient. The patient understands that delinquent accounts are subject to finance charges and collection fees, and that special financial arrangements can only be made with an addendum to this document. PATIENT AGREEMENT: stated.
I have read and understand the financial policy above and agree to the terms
_____________________________________ ______________________________________ Patient’s Signature/Guardian
Date
MEDIGAP: If you have a supplemental policy and it is a MEDIGAP policy to which your Medicare Carrier automatically “crosses over”, we are required to keep a separate signature on file: I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize the Practice to release to my MEDIGAP carrier any information needed to determine benefits or the benefits payable for related services.
_____________________________________ ______________________________________ Signature as it appears on Medigap Card
Date
