Document 6428014

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.