Divine Dermatology, PLLC
2100 Dr. Martin Luther King Jr. St. N
St. Petersburg, FL 33704
Phone: 727-528-0321
Fax: 727-498-8832
*Patient Information Sheet*
Date: ______
Name: ______
SSN: ______Date of Birth: ______Age: ______
Address: ______Apt. ______
City: ______State: ____ Zip Code: ______
Home Phone: ______Work Phone: ______Cell Phone: ______
Email: ______
Marital Status: S M W D Spouse’s Name: ______
Employer: ______
Employer Address: ______
Employer Phone Number: ______
Primary Physician’s Name: ______
Physician’s Number: ______Location: ______
Emergency Contact: ______
Relation to Patient: ______
Telephone: ______Legal Guardian (if applicable): ______
Please provide us with the following at the time of your appointment:
- Government issued photo ID
- Insurance cards (when applicable)
Divine Dermatology
2100 Dr. Martin Luther King, Jr. St N
St. Petersburg, FL 33704
Phone: (727) 528-0321
Fax: (727) 498-8832
Medical History Questionnaire
Patient Name______Date ______
Birth Date ______
Current Complaint ______
* Do you or anyone in your family have a history of skin cancer? Y N
* Do you or anyone in your family have abnormal moles-dysplastic
or malignant melanoma? Y N
* Does anyone in your family have skin problems? Y N
* Has a doctor ever given you anything for your skin? Y N
* Are you prone to the formation of keloids or large scars? Y N
* Are you here for work related skin problems? Y N
Please circle any of the following diseases or conditions you may have had:
Mitral Valve Prolapse
Heart Pacemaker
Radiation Treatment
Ulcers (Stomach)
Blood Transfusion
Nervous Problems
Blood Clots
TB
HIV
« We also specialize in the following cosmetic procedures »
Please circle for further information
· Blue Light Acne Treatments
· Botox Cosmetic Injections
· Cellulite treatments
· Chemical & Fruit Acid Peels
· Cleansing European & Acne Facials
· Dermal Fillers-for wrinkles/scars
(Juvéderm, Restylane, Perlane and Radiesse)
· Hair Loss Therapy Laser
· Facials and Treatments (for age spots, broken capillaries, wrinkles, acne scarring, and stretch marks)
· Mesotherapy (lipo-dissolve) for fatty areas
· Microdermabrasion
(skin smoothing treatments)
· Skin Rejuvenation
· Spider Vein Treatments
· Thermage (non-surgical skin tightening & lifting for both body and face)
Carol Sims-Robertson, MD - Divine Dermatology PLLC
HIPAA PATIENT CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review or Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or healthcare operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and healthcare operations. You have the right to revoke this Consent in writing. However, such a revocation shall not affect any disclosures we have already made in accordance with your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Patient understands that:
v Protected health information may be disclosed or used for treatment, payment or healthcare operations.
v The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
v The Practice reserves the right to change the Notice of Privacy Practices.
v The Patient has the right to restrict the uses of their information, but the Practice does not have to agree to those restrictions.
v The Practice may revoke this Consent in writing at any time and all future disclosures will then cease.
v The Practice may render treatment upon the execution of this Consent.
Signature: ______Date: ______
Printed name: ______
(Printed name of patient or representative and relationship to patient)
Witness: ______Date: ______
(Practice representative)
Divine Dermatology
2100 Dr. Martin Luther King, Jr. St N
St. Petersburg, FL 33704
Phone: (727) 528-0321
Fax: (727) 498-8832
PATIENT: ______DOB: ______
Financial Policy
*Please take the time to review the following billing and collection policy*
Medicare:
We are participating Medicare Providers and will submit your claim. Any applicable deductibles will be required.
Secondary/Co-Insurance Coverage:
These insurances will be submitted “ONE TIME ONLY”. If you do not have secondary coverage to Medicare, then you will be required to pay 20% of the Medicare allowable.
HMO, PPO and other managed care insurance plans: You will be required to pay your co-payment at the time of service. We will then file the claim with your insurance company.
Private/Commercial Insurance Carrier: If we “DO NOT” participate with your insurance, payment for office visits will be due after we file your claim. If you are here for any diagnostic testing then you will be required to pay 20% after we file your claim.
Payment made prior to being seen: All applicable co-payment/deductibles and outstanding balances will be collected prior to being seen on the day of your appointment. If payment cannot be made, your appointment will be rescheduled.
No Show Policy: There will be a $50.00 charge for not showing up for an appointment more than twice within a
1 year period without a 24 hr notice of cancellation.
Divine Dermatology’s filing of insurance claims on the patient’s behalf does not relieve the patient of the financial responsibility for settling their account.
We accept the following types of payment: Cash, Visa, Master Card, American Express and Discover.
I authorize the release of any medical or other information acquired in the course of treatment as necessary to file insurance claims or to another medical provider related to my care. I also authorize payment directly to the physician for medical/surgical care, that would otherwise be payable to me. I realize that I am responsible for any services that are non-covered by my insurance. The payment (and/or spouse/guarantor) is responsible to pay all sums unpaid by insurance. If it becomes necessary to collect any sum due through an attorney, then the patient (and/or spouse/guarantor) agrees to pay all reasonable costs of collection, including attorney’s fees, whether suit is filed or not.
Please sign below indicating you have read and agree to Divine Dermatology’s financial and office policies.
X______X______
(Patient) (Date) (Spouse or Guarantor) (Date)
Divine Dermatology
2100 Dr. Martin Luther King, Jr. St N
St. Petersburg, FL 33704
Phone: (727) 528-0321
Fax: (727) 498-8832
*NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT FORM
AND
PERMISSION TO RELEASE MEDICAL INFORMATION*
PATIENT: ______DOB: ______
DATE: ______
Divine Dermatology has developed a comprehensive policy to preserve our patient’s confidential medical information also called “protected health information”. This Notice of Privacy Practices is available for you to read and review in the lobby of our office. A printed copy of the notice is also available to you upon request.
I hereby acknowledge that this information has been made readily available to me and I have had the opportunity to review the information contained therein.
X______
(Patient) (Date)
X______
(Printed name of Family/Significant other) (Date)
X______
(Practice Representative) (Date)
In addition, I hereby give my permission for my Protected Health Information to be released, when necessary, to the following individuals, who are also my emergency contact(s):
Name:______Relationship to Patient:______
Phone #:______
Name:______Relationship to Patient:______
Phone #:______
This information may include, but is not limited to, confirmation of appointments, test results, medication changes, progress reports, etc. I may withdraw this permission at any time by informing Divine Dermatology’s staff in writing.
Phone #: ______Phone #: ______
Divine Dermatology, PLLC
Carol Sims-Robertson, MD
2100 Dr. Martin Luther King, Jr. St N
727-528-0321
· INSURANCE COMPANIES SET THE AMOUNTS THEY WILL PAY FOR SERVICES.
· INSURANCE COVERAGE IS A CONTRACT BETWEEN MY INSURANCE COMPANY AND MYSELF. MOST POLICIES HAVE DEFINED DEDUCTIBLES, CO-PAYS AND/OR YEARLY MAXIMUMS.
· IT IS NOT THE RESPONSIBILITY OF THIS OFFICE TO KNOW WHAT MY DEDUCTIBLE AND/OR CO-PAYS ARE.
· PHONE VERIFICATION OF BENEFITS DOES NOT GUARANTEE THAT I AM COVERED.
· I AM RESPONSIBLE FOR ANY BALANCES DUE.
· PAYMENTS FOR ALL CO-PAYS ARE DUE AT THE TIME OF SERVICE.
I HAVE READ THE ABOVE AND AGREE TO BE RESPONSIBLE FOR ALL PAYMENTS AND CO-PAYS TO THIS OFFICE.
SIGNATURE DATE
WITNESS DATE