Medical History and Intake Form First Name(Required)Last Name(Required)Date of Birth(Required)Email Address(Required)Race American Indian or Alaskan Native Asian Black/African American Native Hawaiian or Other Pacific Islander White Decline to specify Other Ethnic Group Hispanic Latino Not Hispanic or Latino Unknown Decline to specify Preferred Language English Decline to specify Other How did you hear about our clinic?Choose an Option(Required) Physician Friend or Relatives Google Social Media Other Who is your primary care provider?First NameLast NameCredential M.D. D.O PA-C ARNP PhoneWhat is the name of the provider who referred you to our clinic?First NameLast NameCredential M.D. D.O PA-C ARNP PhoneDo you have a living will? Yes No Our Providers participate in E-Prescribing. Please provide the following informationPharmacy NamePhoneAddress Street Address City Past Medical History (Check all that apply. If none, please check none) None Atrial Fibrillation CVA-Stroke COPD Coronary Artery Disease Diabetes End Stage Renal Disease Immunosuppression Leukemia Lymphoma Radiation Treatment Past Surgical History (Check all that apply. If none, please check none) None Basal Cell Cancer Surgery Melanoma Surgery Squamous Cell Cancer Surgery Shoulder Joint Replacement (Right, Left, Bilateral) Knee Joint Replacement (Right, Left, Bilateral) Hip Joint Replacement (Right, Left, Bilateral) PTCA (angioplasty, heart stent) Biological Heart Valve Replacement Mechanical Heart Valve Replacement Pacemaker Heart Transplant Skin Disease History (Check all that apply. If none, please check none) None Actinic Keratosis (AK's) Basal Cell Skin Cancer Dysplastic nevus of skin (precancerous moles) Melanoma Psoriasis Squamous Cell Skin Cancer Other If you answered "yes" to shoulder, knee or hip replacement surgery, please provide the surgery date here.Do you wear sunscreen? Yes No What SPF?Do you tan in a tanning salon? Yes No Family History of Melanoma? Yes No If yes, whom?Medications (All current medications including non-prescription and birth control; if none, mark N/A)Medication or Latex Allergies (Please list any allergies that you have, and the reaction you had. if none, mark N/A)Social historySmoking History Non-Smoker Former Smoker Current Smoker Alcohol History None 1 or less per day 1-2 per day 3 or more per day IV Drug Use No Yes Review of SystemsSwollen Lymph Nodes Yes No Pregnant or current trying to become pregnant Yes No Changing Moles; Other than primary reason for visit Yes No Problem with Healing Yes No Chest Pain Yes No Shortness of Breath Yes No Cough Yes No Unintentional Weight Loss Yes No Fever or Chills Yes No Headaches Yes No Anxiety Yes No Do you have a Defibrillator? Yes No Do you have a Pacemaker? Yes No Do you have an Artificial Heart Valve? Yes No Have you had Artificial Joint Surgery in the past 2 years? Yes No History of Rapid Heart Beat with Epinephrine? Yes No Are you taking Blood Thinning Medication? Yes No Do you have a history of Bleeding Disorders? Yes No Do you require Antibiotics prior to procedures? Yes No History of Allergy to Band Aids or Adhesive Tape? Yes No History of Keloid or Hypertrophic Scarring? Yes No History of MRSA (Resistant Staph Infections)? Yes No Do you have HIV/AIDS? Yes No Do you have a history of Hepatitis B or C? Yes No Patient InformationName First Middle Last GenderDate of BirthSocial Security NumberMarital StatusAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address: EmployerJob TitleHome PhoneCell PhoneWork PhoneMay we leave a message on voicemail/answering machine for appointments, test results, and instructions? Yes No Phone number where we should leave a message Home Phone Cell Phone Work Phone Person to Notify in the Event of EmergencyNameRelationshipPhoneInsurance Party Information (Copayments and deductibles are expected at time of service)Primary InsurancePolicy Holder's NamePolicy Holder DOB/Relationship to PatientSubscriber IDSecondary InsurancePolicy Holder's NamePolicy Holder DOB/Relationship to PatientSubscriber IDRelease of Medical Records InformationRelease of Medical Records Consent(Required) I agree to the release of medical records to the following people..I authorize SSCO to release information with regard to my care and treatment to the following individuals/family members:NameRelationshipPhoneNameRelationshipPhoneLegal InformationAssignment of Benefits, Notice of Privacy Practices, Consent for Communication, and Payment Policy I agree to the Assignment of Benefits, Notice of Privacy Practices, Consent for Communication, and Payment Policy.Assignment of Benefits: The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Skin Surgery Center of Oklahoma and its related companies. I understand that I am financially responsible for any balance. I also authorize Skin Surgery Center of Oklahoma and its related companies, or insurance company to release medical information required to process claims. Notice of Privacy Practices: I have read or been offered a copy of Skin Surgery Center of Oklahoma Notice of Privacy Practices (NPP), which explains how my medical information will be used and disclosed. I authorize the release of my medical information necessary to provide care and bill on my behalf. I understand I am entitled to a copy of the NPP. I authorize pictures of myself and of clinical focus areas to be stored in my medical record. Consent for Communication: I understand Skin Surgery Center of Oklahoma will send appointment reminders and information on services via telephone, text message, and/or email based on contact information I provided. I understand that I will have the option to opt out of future text/email reminders. Payment Policy: Payment is due at time of service including copays, deductibles, non-covered and cosmetic procedures, and prior balance due. I understand I am responsible for all charges for services rendered on my behalf, or on behalf of my dependents, less any amount paid by insurance to Skin Surgery Center of Oklahoma and its related companies. Legal: This form applies to Skin Surgery Center of Oklahoma and its related companies. Financial Policy, Consent, and HIPAA Acknowledgment(Required) I agree to the following.Checking this acknowledgment indicates that I have been given the opportunity to review this information, ask questions and have had my questions answered. I understand that I am financially responsible for all services as described in this consent form. Agreement for Services: I agree to the services that may be performed by Skin Surgery Center of Oklahoma physicians and nonphysician providers. I understand I can withdraw from this agreement at any time. I understand that except in an emergency, no major procedure or treatment will be performed without providing me an opportunity to give informed consent, meaning the provider will first provide me with information including the nature of the procedure or treatment, risks, benefits and alternatives. Insurance Billing: I consent for the practice to bill my insurance company according to the most recent insurance information and insurance card(s) including, Medicare and Advantage Plan cards, that I have provided. I understand that all payment of all balances is my responsibility, including copays, co-insurance amounts, deductible amounts and services that are not covered by my insurance plan (such as cosmetic services). I understand that if claims are denied due to lack of current insurance information, I will be responsible for the balance. Insurance Network: I understand that it is my responsibility to ensure that this practice and the provider of services are in my insurance network. If my plan requires a referral from my PCP, it is my responsibility to obtain the referral. If my claim is denied because I am out of network or failed to obtain a referral, I understand that I will be responsible for the balance. Co-payment: I understand all co-payments must be paid at the time of service. I understand co-payment and co-insurance are determined by my insurance. The practice accepts cash, check, Visa, MasterCard, American Express, Discover and Care Credit. Deductible: An annual deductible is the dollar amount I must pay out of pocket during the year for medical expenses before my insurance begins to pay. Images and Monitoring: I understand that the Skin Surgery Center of Oklahoma may make and use photos or other images for identification, diagnosis, treatment, performance improvement and education purposes. I consent to such images with the understanding that any images are not readily available to visitors or the public and will not be disclosed except as required or permitted by law. Determining Guarantor: The guarantor is the responsible party held accountable for this patient’s bill. The guarantor is always the patient if they are over the age of 18. The guarantor for a minor child is the parent that presents the child for care at the time of the initial visit. Self-Pay: I understand and agree that if I do not have insurance or opt out of Insurance coverage if permitted and elect to be seen as a self-pay patient, I have full financial responsibility for my visits and will pay for all services at the time of service, unless other arrangements have been made. I understand I will be subject to and will abide by the practice’s self-pay policy. This agreement will remain in effect unless proof of insurance is provided at a subsequent date. Pathology Processing Charges: I understand that any biopsy or removal of lesions performed during my office visit will be sent to an outside pathology lab for processing. All charges and billing for these services will be processed by the lab. These charges are separate from my visit at Skin Surgery Center of Oklahoma, and I understand that I will receive a separate statement from the lab. Past Due Balances: I understand that if my account is over 90 days past due, this practice will send a statement and I will have 20 days in which to pay the balance in full. Partial payments will not be accepted unless previously negotiated. I understand that if the balance remains unpaid this practice may refer my account to a collection agency and/or I may be dismissed from this practice. Late Arrivals or Missed Appointments: I am aware that if I am late to my appointment I may be rescheduled. I also understand that multiple missed appointments without adequate notice and/or late arrivals may result in my dismissal from the practice. If I am unable to keep my appointment, I will notify this office at least 24 hours in advance. HIPAA Disclosure and Notice of Privacy Practices: I consent for this practice to release information to my insurance company, primary care/referring physician, and any other covered entities in accordance with the HIPAA Privacy Act. I understand that medical information disclosed may be used and forwarded to provide continuing treatment or care, for filing claims, and for all other healthcare operations. I have received this practice’s Notice of Privacy Practices for Protected Health Information for a more complete description of the potential uses and disclosures of such information. I have had the right to review such notice prior to signing this consent form. This form applies to The Skin Surgery Center of Oklahoma and its related companies.Today's Date(Required) Month Day Year
