Clone of Natural Image Skin Center Registration Form

Natural Image Skin Center Registration Form
Patient Registration Type *

New Patient Name Change Address Change Insurance Change
Patient Information *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
Cell Phone
Home Phone
Preferred Method of Contact
Primary Care Provider
Emergency Contact

First Name Last Name
Relation To Patient
Cell Phone
Present ALL insurance cards to the receptionist. If a patient is a minor & you are not the legal guardian, please contact us immediately.
Primary Insurance

Carrier Policy Number
Secondary Insurance

Carrier Policy Number
Subscriber Name

First Name Last Name
Subscriber DOB

Month Day Year
HIPAA PRIVACY POLICY: Patients over the age of 18 are protected under the Federal Health Insurance Portability and Accountability Act. This Federal Law prohibits any staff member of Natural Image Skin Center from discussing appointments, medication, test results or treatment plans with anyone other than the patient. Often, this causes difficulty for some patients who would like family members or caretakers to obtain information for them. If you would like to permit someone to discuss your medical condition, confirm appointments or obtain results for you, please indicate their name(s) below. Should you wish to update the names provided below, please ask the receptionist for a HIPAA form. Natural Image Skin Center cannot give any medical information to persons who are not listed on this form.
Authorized to discuss patients health information

First Name Last Name Relationship
Authorized to discuss patients health information

First Name Last Name Relationship
*

I acknowledge that I understand the above policy and I have received a copy of the practice’s Notice of Privacy Practices (if requested) related to the Health Insurance Portability and Accountability Act of 1996.
Signature *

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Patient Acknowledgement of Office Policies

APPOINTMENT CANCELLATIONS:
If I am unable to keep my scheduled appointment, I will call Natural Image Skin Center to cancel or re-schedule my medical appointment at least 24 hours in advance. Cosmetic and Surgical appointments require 48-hour cancellation notice. If I do not call Natural Image Skin Center to cancel my appointment as outlined above, I understand I will be required to pay a $25.00 no show fee for office visit, $50 for cosmetic procedures $100.00 for surgical visit and $200 for Moh’s Surgery.

CO-PAYMENTS:
Co-payments are due and collected on the day of my or my family’s appointment. It is my responsibility to know my co-payment amount.

INSURANCE REFERRALS:
If my insurance plan requires a referral, I understand it is my responsibility to obtain an updated referral from my Primary Care Provider and to make sure that Natural Image Skin Center has the referral before my visit. I understand it is my responsibility to keep track of the number of visits I have used on the referral and the expiration date and obtain new ones as needed. I understand should I fail to have a valid referral for my visit, and I am seen, I will be considered a self-pay patient and will be responsible for all charges incurred. I understand my insurance company will not cover any visit where a valid referral is not in place. Patients who are seen without a referral at the time of visit must provide a credit card on file and will be charged as “self-pay”.

INSURANCE CARDS:
We require you to confirm your insurance is current at each office visit. New patients or existing patients with a change in their insurance information must provide a valid insurance card or temporary print out at the time of the visit. Should I be unable to produce this documentation, I understand I will pay in full at the time of service and submit the claim to my insurance company myself. I understand that in signing below, I am responsible for notifying Natural Image Skin Center of any changes to my insurance or contact information and if my plan requires a referral. If the insurance information or referral information I present at my visit is not correct, I understand I am responsible for all charges.

ACCOUNT BALANCES:
I am responsible for the timely payment of my account balances, co-insurances and deductibles. All balances are due within 30 days of my first billing. Any balance left unpaid after 90 days without attempt at resolution will be considered for collections and may be submitted to a collection agency which will make reports to agencies that will affect my credit. If I am having financial difficulty, I understand I may contact the billing office to discuss a reasonable payment plan. If my account is sent to collections, I understand there will be an additional 15% of the total charges added to the principle balance for administrative fees as well as being responsible for any attorney and court charges that may arise from my account being sent to collections.
MINOR PATIENTS:

A legal guardian must accompany children under the age of 18 to their initial appointment so that legal forms may be completed and signed. Follow up visits do not require a guardian to be present unless a procedure is being performed that requires a signed consent form.
Consent to office policies *

I have read the Patient Office Polices
Signature *

Clear

Informed Patient Consent

I give my permission for the Physicians and staff of Natural Image Skin Center to treat me as deemed necessary in the expertise of their professional judgement.

I understand that medical care requires my cooperation, and I will follow my doctor’s orders and prescriptions. If indicated, I will make and keep appointments for follow-up care and call the office to note any changes or concerns in my condition.

I authorize my doctor to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such medical care to third party payers, including Medicare.

I authorize and request that my insurance company, in lieu of reimbursing me directly, pay to the doctor or medical group any benefits for services rendered.

I understand that my medical insurance carrier may pay less than the actual bill for services. I agree that I may be responsible for payment of all services rendered on my behalf or my dependents.

I understand I may be billed by an outside laboratory for work that is performed in this office, if my insurance company does not have a contracted lab or facility, or if services are not covered by my insurance company.

In the event that I chose to provide Natural Image Skin Center(“NISC”) with my e-mail address, I hereby authorize NISC to contact me using the e-mail address(s) I provided, and agree to allow NISC to continue to contact me using e-mail until I advise NISC, in writing, that they no longer may contact me using e-mail. In return for allowing NISC to contact me using e-mail, NISC promises not to release, sell or otherwise distribute any e-mail address(s) I provide to any other person or entity without my express written authorization.

I authorize the physician(s), mid-level providers or staff of Natural Image Skin Center to educate me regarding skin care products or devices suitable for my disease state or diagnosis. I understand that I can opt-out from receiving this information at any time by writing to Privacy Officer, 108 Bilby Road Suite 202 Hackettstown, NJ 07840.
Informed Patient Consent *

I hereby certify that I have read natural Image Skin Center's Informed consent and fully understand the contents thereof.
Signature *

Clear

CONSENT TO TELE HEALTH VISIT

The purpose of this form is to get your consent for a telehealth visit with dermatologists Dr Nicole Rocca and Dr Stephen Nervi at Natural Image Skin Center. The purpose of this visit is to help in the care of your skin problem.

How Telehealth Works: In a telehealth visit you will interact in real time with your dermatologist via a secure, online videoconferencing technology. Your dermatologist has the right to discontinue or not provide a consult via videoconference or secure electronic messaging should the videoconference connection or the forwarded image be of poor quality. You may be required to make an in-person appointment for further evaluation should this occur.

The dermatologist will look at the patient's skin during a videoconference. The dermatologist will then give you advice about your dermatologic condition and how to treat and take care of your condition. The information from the dermatologist will not be the same as a face-to-face visit because the dermatologist is not in the same room.

Pros, Cons and Your Options: With telehealth, a dermatologist will advise you based on viewing your condition during a videoconference. Sometimes a face-to-face follow-up visit with the dermatologist may still be needed. If you do not come into the office for an in-person visit, the dermatologist's advice will be solely based on the viewing your skin condition during a videoconference. In the absence of an in-person physical evaluation, the dermatologist may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of your condition and recommended treatment. It is possible that there will be errors or deficiencies in the transmission of the images of your skin condition during the videoconference that may impede the dermatologist's ability to advise you about your condition. Also, very rarely, security measures can fail to protect your personal information, but the company that is providing the technology for your telehealth visit has extensive security measures in place to prevent such failures from happening.

Presence of Others During Telehealth Visit: Our Medical Assistants may be a part of the patient's care and present during a telehealth visit. Anyone that is part of the telehealth team will be supervised by the dermatologist, and the final recommendations about your care will come from the dermatologist. Also,
non-medical people may help to set up the telehealth equipment. You may ask for persons other than your dermatologist to leave the room if you are uncomfortable having them participate in your telehealth visit.

Medical Information and Records: All federal and state laws covering access to your medical records (and copies of medical records) also apply to
telehealth. No one other than the health care team described above can view your photos or information unless you agree to give them access.

Privacy: All information given at your telehealth visit will be maintained by the doctors, other health care providers, and health care facilities involved in your care and will be protected by federal and state privacy laws.

Your Rights: You may opt out of the telehealth visit at any time. This will not change your right to future care or health benefits.

Waiver/Release: By signing below, you understand and agree that you solely assume the risk of any errors or deficiencies in the electronic transmission of information during your telehealth visit or in the electronic submission of your images to your dermatologist and further understand that no warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis. To the extent permitted by law, you also agree to waive and release your dermatologist and his or her practice from any claims you may have about this advice or the telehealth visit generally. The consent provided in this document will expire in one year from the date you sign it, but your waiver and release shall apply indefinitely for any telehealth visits that occur during the one-year period after your signature date.

My doctor has talked with me about the telehealth visit. I have had the chance to ask questions and all of my questions have been answered. I have read this form, understand the risks and benefits of the telehealth visit, and agree to a telehealth visit under the terms explained above.

I acknowledge that I will be held responsible for any cost to my telehealth visit that my insurance does not cover.
Consent to Telehealth *

I consent to Telehealth I do not consent to Telehealth

ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICES OF NATURAL IMAGE SKIN CENTER, LLC
Type a question *

I hereby acknowledge that I have received from Natural Image Skin Center, LLC (“NISC”), a copy of the Notice of Privacy Practices of NISC. I understand that the Notice of Privacy Practices sets forth my rights relating to the use and disclosure of my personal health information and explains how NISC can use and disclose my personal health information both with and without my authorization. I further understand that I may contact NISC or its Privacy Officer if I have any questions regarding the contents of this Notice or to file a complaint.
Signature *

Clear
Should be Empty:

Natural Image Skin Center Registration Form

Patient Acknowledgement of Office Policies

ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICES OF NATURAL IMAGE SKIN CENTER, LLC