Shen Dermatology New Patient Registration

Days: Monday, Tuesday, Thursday, Friday
Hours: 8 AM to 1 PM

This is a secure form. Upon processing this form you will receive a call from the office to arrange an appointment date and time. Please note that online registration forms submitted after 4 p.m. will be processed the next business day. Any forms submitted over the weekend, or holidays will be processed the next business day.

Were you given an appointment date and time over the phone or in person?

Yes No

First Choice Appointment Request:*

:

Please use the date and time picker.

Second Choice Appointment Request:*

:

Please use the date and time picker.

Full Patient Name*

First Name

Initial (optional)

Last Name

Date of Birth*

Marital Status:

Single Married Divorced Legally Separated Widowed

Address *

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Email*

Confirm Email *

Primary Contact Phone Number*

Secondary Contact Phone Number

Primary Insurance Type:*

Insurance Company Name:*

Responsible Party Name:*

First Name

Last Name

Responsible Party Date of Birth:*

Responsible Party Social Security Number:*

Primary Insurance PO Box Billing Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Primary insurance Subscriber ID:*

Primary Insurance Group Number:*

Secondary Insurance Type:

Responsible Party Name:

First Name

Last Name

Responsible Party Date of Birth:

Responsible Party Social Security Number:

Secondary Insurance PO Box Billing Address (NOT YOUR HOME ADDRESS):

Address Line 1

Address Line 2

City

State

ZIP Code

Secondary insurance Subscriber ID:

Secondary Insurance Group Number:

First Chief Complaint

How long have you had these symptoms?*

Second Chief Complaint

How long have you had these symptoms?

Are you taking any medications:*

I am not taking any medications. I am taking medications.

My medications:

Emergency Contact:*

First Name

Last Name

Emergency Contact Relationship:*

e.g. Father, Mother, etc.

Emergency Contact Phone:*

May we leave a message at home?*

Yes No

May we leave a message on your cell phone?*

Yes No

May we leave a message with a household member?*

Yes No

Have you ever had melanoma?*

Yes No

If yes, what year(s) was it found?

If yes, what was location(s) on your body?

Is there a family history of melanoma?*

Yes No

If yes, what is there relationship to you?

If yes, what was the year and location on their body?

Have you ever had a Squamous Cell Carcinoma?*

Yes No

If yes, what is there relationship to you?

If yes, what was the year and location on their body?

Have you ever had a Basal Cell Carcinoma?*

Yes No

If yes, what is there relationship to you?

If yes, what was the year and location on their body?

Do you have hypertrophic scars or Keloids?*

Yes No

Are you immunosuppressed?*

Yes No

Immunosuppression is a reduction of the activation or efficacy of the immune system.

Have you ever smoked?*

Never Yes Quit

How many years did you smoke?*

How many packs on average did you smoke per day?*

Do you drink alcohol?*

Yes No

Have you ever had a heart or hip replacement?*

Yes No

Are you currently taking blood thinners such as Coumadin or Plavix?*

Yes No

Do you ever experience chronic nausea or vomiting?*

Yes No

Do you have a mitral valve prolapse?*

Yes No

Improper closure of the valve between the heart's upper and lower chambers.

Are you pregnant?*

Yes No Not Applicable

List any specific skin diseases or medical conditions:

Occupation and Hobbies:

Drug Allergies*

No known drug allergies I have drug allergies

My drug allergies:

Preferred Pharmacy Name:

Preferred Pharmacy Address:

Address Line 1

Address Line 2

City

State

ZIP Code

PRACTICE FINANCIAL POLICY

In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following policy. If you have any questions about the policy please discuss them with our office manager. We are dedicated to providing the best possible care and services to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment.

YOUR INSURANCE

We have made prior arrangements with many insurers and other health plans to accept an assignment of benefits. We will bill those plans for whom we have an agreement and will only require you to pay the authorized co-payments, at the time of service. It is the policy of our office to collect any payment due when services are rendered.

If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an assigned basis. Typically out-of-network benefits are lower therefore; you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.

WORKER’S COMPENSATION

We do not participate in worker’s compensation cases.

COLLECTION POLICY

Any unpaid balance will accrue 1.5% finance charge monthly after the account has lapsed for 60 days. In the event that any balance due hereafter is not paid as agreed, the undersigned jointly severally agrees to pay all costs charged by the collections company, which will not exceed 35% of said balance, including a reasonable attorney’s fee.

CREDIT CARD POLICY

WE ACCEPT VISA, MASTERCARD, AMERICAN EXPRESS AND DISCOVER FOR YOUR CONVENIENCE. This in no way will compromise your ability to dispute a charge or question your insurance company's determination of payment.

CRYOSURGERY/LIQUID NITROGEN

Frequently cryosurgery/ liquid nitrogen is administered to the skin to destroy pre-cancerous lesions (actinic keratosis) and to aid in the diagnosis of skin cancers. I authorize Dr. Shen to use liquid nitrogen treatment if he deems it medically necessary.

MINOR PATIENTS

For all services rendered to minor patients, we will look to the adult (parent or guardian) accompanying the patient with custody for payment.

MISSED APPOINTMENTS

In order to provide the best possible service and availability to all our patients, please call us as early as possible if you know you will need to reschedule your appointment. If you miss your appointment we will reschedule you as best as we can with our availability.

PRIOR AUTHORIZATION

Our practice does not approve prior authorization for prescriptions & procedures. By prescribing with less costly generic medication and price comparison, we have committed ourselves to provide the best medication needed for your diagnosis.

I authorize benefit amounts payable by the insurance company assigned directly to the provider. I have read and understood the financial policy of the practice and agree to be bound by its terms. I understand and agree that such terms may be amended from time-to-time by the practice.

Signature for Practice Policies - Copy*

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Use your mouse or finger to draw your signature above

Date Signed*

NOTICE OF PRIVACY, CONSENT, AND HIPAA

I understand that under the Health Insurance Portability & Accountability Act of (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that my information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Signature for Privacy, Consent, and HIPAA*

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Use your mouse or finger to draw your signature above

Date Signed*

Authorization for Consent to Skin Biopsy

A biopsy is done to help make a diagnosis and may not result in complete removal of the biopsied lesion.
If the biopsy shows that the lesion is benign, no further treatment may be needed.
If the biopsy shows skin cancer, additional treatment will be needed to attempt to remove all cancer cells.
The skin heals by permanent scar formation. Scars can heal thick or thin. Bleeding, infection and pain are rare complications of a biopsy
Lidocaine and epinephrine numbing medicine will be used. Serious reactions to lidocaine and epinephrine are very rare. Please inform us if you are allergic to either of these.
We send our specimens to the University of Miami. If the insurance does not cover the full amount of the bill, the patient is responsible for the bill. If you are a self-pay (no insurance) patient, the pathology cost will be $80.00 per removal and will be billed to you.
Moles removed for cosmetic reasons are not covered.

Signature for Authorization for Consent to Skin Biopsy*

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Date Signed*

Patient Consent for Research and Publication

I hereby give my consent for images and other clinical information relating to my case to be reported in a medical publication.

I give my consent for images relating to my case to be collected by Shen Dermatology to study the effects of combination topical immunotherapy treatment using machine learning or image processing techniques.

I understand that my name and initials will not be published and that efforts will be made to conceal my identity, but that anonymity cannot be guaranteed.

I understand that the material may be published in a journal, website, or other forms of publication and may be included in medical books. As a result, I understand that the material may be seen by the general public.

Are you the patient?

Yes No

Other:

Do you Decline Consent for Research and Publication

Yes No

Signature for Patient Consent for Publication*

First Name

Last Name

What is your relationship to the patient?*

The person giving consent should be a substitute decision maker or legal guardian or should hold power of attorney for the patient.

Why is the patient not able to give consent?*

e.g. a minor, incapacitated

Date Signed*

This is a secure form. Upon processing this form you will receive a call from the office to arrange an appointment date and time. Please note that online registration forms submitted after 4 p.m. will be processed the next business day. Any forms submitted over the weekend, or holidays will be processed the next business day.

Shen Dermatology New Patient Registration

Days: Monday, Tuesday, Thursday, FridayHours: 8 AM to 1 PM

First Chief Complaint

Second Chief Complaint

Days: Monday, Tuesday, Thursday, Friday
Hours: 8 AM to 1 PM