MOUNT SINAI DERMATOLOGY ASSOCIATES- PATIENT INFORMATION Date [] New Name D Update Last Middle Initial First Name of parent or guardian (if a p p l i c a b l e ) - - - - - - - - - - - - - - - - - - - Add~a ____________~----------~~~---------~--~----=-~~ Street No. Apt. No. TeiNo~ Home---~------ Cityffown State Cell _ _,________ Work Area Code ArcaCodc Zip Code Ext. _ __ An:a Code E-maU ------------------------~~--~~~----------------Preferred Mode ofContaet ( ) Cell ( ) E-mail ( ) Home Phone ( ) Work Phone Date of Birth Age SS## I I _ __ Mo/DayiYear Spowe'sName _ _ _ _ _ _ _ _ Yourgender( )M ( )F Marital Status------- Preferred Language Race-----------Ethnieity Check One ( ) Hispanic or Latino or Spanish Origin ( ) Nm Hispanic or Latino or Spanish Origin Oeeupadon _____________________________________________________________ Name of Employer - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Employer's Address - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Zip Code Street Cityffown State Name of Referring Physician - - - - - - - - - - - - - - - - - - - - T e l No.__________ Physician's Address---~---------------~------------------Street City Zip Code *Penon to Contact in: ______________________________ Case or Emergency Name Tel. No. with Area Code * Relationship Insurance Information Please have insurance identification card(s) available for office staff. PRIMARY INSURANCE Insurance Company Claims Mailing A d d r e s s - - - - - - - - - - - - - - - - - - - - - - - - - - - - Tel No. 10 No.-::------:------------Group Number _ _ _ _ _ _ _ _ _ __ Name of Insured Relationship to Patient Insured's Birth Date Insured's Employer ------------ Add~------------------------------------------------------------ Tcl.No. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - SECONDARY INSURANCE lnsurance Company Claims Majling A d d r e s s - : - : - - - - - - - - , - - - - - - - - - - - - - - - - - - - - - - - - Tel No. lDNo. ---------------------~G~ro--up~N~-um~b~e-r--------------- Name of I n s u r e d - - - - - - - - - - - Relationship to P a t i e n t - - - - - - - - - - Insured's Birth Date _ _ _ _ Insured's Employer Add~ -----------------Tel.No. __________________________________________ ~'Cd: 04.07.11 GENERAL DERMATOLOGY PATIENT HEALTII HISTORY To help us gh•e you the best pouihle care, please carefully complete all questions on this form. ljyo11 do 110t kno•• the answer to a piJTiicu1111' question. /e(llle It blank. Thank you. Patient's name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ I. Have you ever had or beea treated for aay of the following? Duodenal or peptic ulcer ••••••. 0 Yes 0 No Other Intestinal disease or colitis Uver or gall bladder disease Luna disease (TB, pleurisy, etc.) . Heart disease (mewnalic fever, pacemaker, etc.) High blood pressure Stroke Kidney disease Urinary or bladder prvblem or infection Venereal disease Blood or lymph gland disorder Eye disease (callnCI, c:atarae1 suraery> Anhritiso joint problems or bone disease Thrombophlebitis Caneer Frequent infections of the skin or other areas Neurological disorder Emotionil or psychiatric problem 0 Yes 0 0 Yes iJ 0 Yes 0 o Yes o 0 Yes 0 0 Yes 0 0 Yes 0 DYes 0 0 Yes D 0 Yes 0 0 Yes 0 0 Yes 0 0 Yes 0 0 Yes 0 0 Yes 0 0 Yes 0 0 Yes 0 No No No No No No No No No No No No No No No No No 2. Have you or aay memben or your family had aay or the foUowiag? Please specify whom. Astluna....... 0 Yes 0 No 0 Yes 0 No 0 Yes 0 No Hives 0 Yes 0 No Diabetes 0 Yes 0 No Psoriasis 0 Yes 0 No Skincancer 0 Yes 0 No Glaucoma 0 Yes 0 No Othcrskinconditions(speclfy}O Yes 0 No Hay fever Eczema 0 Self 0 Other _ _ _ _ _ __ 0 Self 0 Other _ _ _ _ _ __ 0 Self 0 Other _ _ _......__ __ 0 Setr 0 Self 0 Self 0 Self 0 Self 0 Self 0 Other------------ 0 Other _ _ _ _ _ __ 0 Other o Other _ _ _ _ _ __ 0 Other------0 Other _ _ _ _ _ __ 3. Have you or uy memben of your ramUy had aay orthe followiag? Please specil'y whom. Exce.ssive bleeding when cur 0 Yes 0 No 0 Self 0 .Other Difficulty with the healing of wounds 0 Yes D No 0 Self 0 O t h e r - - - - - - Overgrown scars or keloids Allergy to local anesthetics 4. 0 Yes 0 No 0 Self 8 Other 0 Yes 0 No · u Self 0 Other Have you previously bad a aida problem or been uDder the describe. -- care of a dermatologist? If yes, please s. Social History Q Yes ::1 No Have you ever had a venereal disease? r. Yes~ No Do you smoke? If yes. how many cigarettes or packs per week? (Specify which) - - - C Yes =' No Do you drink alcohol? If yes. how many drinks do you consume on a weekly basis? Are you m.arried 0 single 0 other 0? If other, please e l a b o r a t e - - - - - - - - - - - - - 6. Have you ever been given X-ray or Grenz lreatments for your skin? li Y'--s :i No 7. Do you take any medicine, drugs or over-the-counter preparations or remedies? 0 Yes i I No (These might include medicines for sleep. constipation, headaches. birth control or "nerves.'") 8. Are you allergic to any medicines, drugs or over-the-counter preparations or remedies? 9. Please provide details of any prior hospitalizations or surgeries: Dates of' HospltallzaUODISurt!HY Reason f'or Hosoltalizatfon/Sunery 0 Yes~; No Outcome I0. For Women Only Have you ever had vaginal yeast infections? ••...•••.•....•.........•..... Are you pregnant? ........................................................... . Are you currently planning a pregnancy? ............................. . rue you nursing? ............................................................ . I I Yes 1.1 No U Yes U No [J Yes !J No ~1 Yes :J No NOTE The dermatologie examination which you are about to receive is NOT a complete physital eum. Therefore, we suggest you have a complete physical examination periodically by your famUy physician or internist. Patient's S i g n a t u r e - - - - - - - - - - - - - - - - D a t e - - - - - - - - - Physiclaa C o m m e n t s - - - - - - - - - - - - - - - - - - - - - - - - - - - Reviewed: 04.07.1 t _________________ Date-:----------Pbysieiaa 's Signature tiOU'l1" sow North Shore Medical Group The Mount Sinai Hospital ofQ!!eens SCMOOL Of "lDICINI ACKNOWLEDGEMENT of RECEIPT of NOTICE ofPRIVACY PRACI'ICES (NOPP) By signing below, I acbwwledge that I have been provided a copy oftlds Notice ofPrivacy Practices and have therefore been advised ofhow health biformation about me may be used and disclosed by the Hospitals andfacilities listed at the beginning ofthis Notice, and how I may obtain accen to and control ofthis lnf07mlllion. Patient- Please PRINT Your NameSigDatuJe ofPatleat and/or Penoaal Represeatative PenoDal Representative- Please PRINT Your Name Description of Penonal Represeatafive's Authority I was not able to obtain the patient '.r acbwwledgement ofreceipt ofthe NOPP upon registration because: 0 0 0 0 The patient refused to sign despite goodfaith efforts. The patient was unaccompanied cmd not alert and oriented. The patient was Ulftlccompanied and needed emergency care. Other(explaln) _ _ _ _ _ _ _ _ _ _ __ Em~OyN'aS~~------------------------------------__________________________________________ Emp~N~nde PriDt Your Name ______________ 0 Date--------- Ac:lmowledgement subsequently obtaiaed (Please see above.) MR·20S (Rev S/04) Mouat SiaaJ Dermatolo§t Associates S East 9th Street - S Floor New York, NY 10029-6574 Claims Authorization for MEDICARE and EMPIRE BLUE CROSS/BLUE SHIELD Patients or Other Health Insurance ALL PRIVATE PATIENTS I understand I am individually responsible for the full payment of the fee(s) for service for all medical services provided by this office. Furthermore, I understand all medical care provided to me or my childlren is on a fee-for-service basis. Finally, I acknowledge that I have been fully informed of the fees for service provided by this office prior to my care. BLUE SHIELD PLAN or OTHER HEALTH INSURANCE I hereby authorize any physician. health care practitioner. hospital. clinic or other medical or medially-related facility to furnish any and all records, medical history, services rendered or treatment given to me or any dependent for purposes of review, investigation, or evaluation of any claim submitted to Empire BlueCross and BlueShield or other insurer. I also authorize Empire BlueCross and BlueShield or other insurer to disclose to a hospital or health care service plan. self-insurer, or any insurer, any medical infonnation obtained if such disclosure is necessary to allow the processing of any claim. If my coverage is under a Group Conlraet held by an employer, an association. trust fund, union, or similar entity, this authorization also pennits disclosure to them for purposes of utilization review or audit. This authorization shall become effective immediately upon execution and shaJI remain in effect for the duration of any claim or tenn of coverage with Empire BlueCross and BlueShield or other insurer including a reasonable time thereafter, until its final consummation. This authorization shall be binding upon me, my dependents, and our heirs, executors and administrators. MEDICARE I request that payment of authorized Medicare Benefits be made either to me or on my behalf to this office for any services furnished by my examining physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any infonnation needed to detennine these benefits or the benefits payable for the related services. AUTHORIZATION TO PAY I request payment of this claim and, if the payor accepts assignment, authorize payment directly to the physician and supplier for the services as described. PAnENT (cr AtmfORIZED INDIVIDUAL) N A M E - - - - - = : - - : : - = - - - - - - - - - PRINT Name PAnENT(or AtmfORIZED INDIVIDUAL) N A M E - - - -..........- - - - - - - Siguature ~;02.10.11 Date--- Mount Sinai Dermatoloi!V Associates 5 East 981h Street- Sill Floor New York, NY 10029-6574 FINANCIAL POLICY Mount Sinai Dermatology is dedicated to providing our patients with tbe best possible care and services while keeping the costs to you fiom increasing at an unreasonable rate. You can play an fmponant role in achieving these objectives by adhering to our financial policy. lasuraa~ We partieipate in severaJ health insurance plans. Please check with our BILLING STAFF to dctennine whether your physician participateS In your plan. If we DO panlclpate, all services performed in our office and in the Mount Sinai Hospital will be submitted to your carrier unless we have received prior notification of non-covered services. All co-pays and deductibles IN your responsibility and you will be billed for these. HMO l11111raaee may require physiclan referral in order to be covered for a service or services. It is your n:spcmsibility as the patient to obtain this referral prior to the time of service. If a referTal is NOT presented at the time ofservice, you will be responsible for payment In fUll for those services on the day of your visit. Every HMO patient is responsible for ALL co-payments at the time ofservice. If we DO NOT participate in your health Insurance plan, we will not bill your canier, and we will not accepl payment from that canicr as payment in fUll for the services perfonned. All insuraac:e c:aniers bave a schedule or rees whicll delermines what they will pay. However, your physician's fees may be more than whal the carrier allows on lis schedule. Therefore. any balance not covered by the insurance canier is your responsibility. Payment for office visits is due at the TIME OF SERVICE. We will provide you with an itemized biU so you may submit the charges for reimbursement IT IS ESSENTIAL THAT YOU UNDERSTAND YOUR HEALTH COVERAGE IS AN AGREEMENT BETWEEN YOU AND YOUR CARRIER. YOUR. PHYSICIAN'S BILL FOR. SERVICES PROVIDED TO YOU IS AN AGREEMENT PETWEEN YOU AND YOUR DOCTOR. Payment for Services Performed Our ofT'ace acceplS VISA. MasterCard, and AMEX as well as personal c:hedcs or cash for your c:cnveaience. All requited payments as outlined above are expec:ted at 1he time of service. A.rJy 01.1tstanding balances are due within 30 days unless you have made prior arrangements with our BILLING STAFF. All payments that reach 9t) days will be sent to our colleaion agency. In the event this happens. you will be responsible. for aU collection and legal fees incurred by our office in the attempt to collect your delinquent balance. Payment In full of any past due balance is expected prior to being seen for another service. In addition, will be expected at the time of service for any services to be provided at that time. In order for Mount Sinai Dermatology to provide the quality of care we offer, you must be willing to do your pan In helping us help you receive insurance benefits for which you may be entitled. payment in full I have read and fully understand the financial policy set Cor by MOUNT SINAI DERMATO LOGY, and 1 agree to the terms ofthls financial policy. I also understand and agree that the terms of the finlulclal policy may be amended by Mount Sinai Dennato!ogy Associates at any time without prior notification to you. SJgaalure or lhe Palient aadlor Patient's Guardian (SEAL) Please PRINT Your Name Date Department of Dermatology 111 S East 98th Street- 5 Floor New York, NY 10029-6574 Tel 212.241.9728 Fax 212.241.1197 Pharmacy Information PatienCs Name _ _ _ _ _ _ _ _ _ _ _ _ _ __ Oatc ofBirtb Telephone NundJcrs - - - - - - - - - - - - Preferred Telephone Nu. Home Please list p!Jarmacies in order ofprefewice: Priman· Plwrmacv Pharmacy Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Address State City Zip Code Telephone Numbcr(s) - - - - - - - - - - - - - - - - - - - - - - - Fax: Number Street Secondarv Pharmacv Pharmacy Name ________________________________________ Address Street City State Zip Cudc Telephone Numhcr(s} - - - - - - - - - - - - - - - - - - - - - - - - - - Fax Number The Mount Sinai North ShOre Medical Group __ Hospital ofQ_uecns .. _., ... tu)UH1' SINAl SCHOOL Of ~ "EDICINE CONSENT for COMMUNICATION via E-MAIL (Provider-Patient) J. -------=-=----=---------J hereby consent to have Please print my physician,--------------~ communicate with me or members of his staff, where appropriate or other physicians, nurse practitioners and pbannacists viae-mailing regarding the following aspects of my medical care and treatment: [test results, prescriptions, appointments, billing, etc.). I understand that email is not a confidential method of communication. I further tmderstand that there is a risk that e-mail communications between my physician and me or members of my physician's office staff; or between my physician and other physicians, muse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any e-mail communications between my physician and me or members of his office staff, or between my physician and other physicians, nurse practition_ers or pharmacists regarding my medical care and treatmcmt will be printed out and made a part of my medical record. I understand that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on e-mail. Signature _ _ _ _ _ _ _ _ _ __ MR-240 (9/03) Date ------------------- MOUNT SINAI USE of INFORMATION AVTHORIZATION Dear Patient, Like other major academic medical centers. Mowtt Sinai depends greatly upon the generosity of our patients to help us provide the finest patient care. to educate the next generation of physicians. and to promote research leading to new treatments and cures. Federal law now requires health care providers to obtain your written authorization prior to contacting you with marketing information or about philanthropic initiatives that support the work of your physician(s). Your pennission for disclosure of your name will allow Mowtt Sinai staff to contact you about marketing or philanthropic efforts that may be of interest to you. No other Information about you or your medleal treatment will be disclosed-that is strictly between you B.Dd your treating physiciao(s). Maintaining patient confidentiality and ensuring your right to privacy has always been and will always be a priority at Mount Sinai. We hope you will take a moment to read this authorization and sign below. If you have any questions. please call the Mount Sinai Development Office at 212.659.8500. Thank you. I authorize any doctor employed by or on the staffofThe Mount Sinai Hospital and The Mount Sinai School ofMedicine ("Mount Sinai •J to disclose my name and contact information to Mount Sinai Development and Public Affairs stafffor the purpose of contacting me about ~\fount Sinai marketing and philanthropic opportunities. I understand that my health care treatment at Mount Sinai will not be affected In any way by my refo.sal or failure to sign this form. I further understand that this authorized information will not be released to any third parties for any purpose other than that expressed above. This authorization will remain in effoct for five years. However, I may revoke this authorization at any time by writing to the Mount Sinai Development Office at OneGustaveL Levy Place, Box 1049, New York. NY 10029-6574. Bysigningbelow,/ aclcnowledge that/ have read and accept all ofthe above. Signature of the Patient Please PRINT Your Name Date Address of Patient Ifapplicable, description ofAuthority ofPersolfDI Representative/Guardian. A signed copy ofthis form Is available upon request by the patient or patient ·s representative.
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