New Patient Paperwork 2023

ADSCI

28049 Smyth Dr, Valencia, CA 91355 | 15477 Ventura Blvd, Suite 100, Sherman Oaks, CA 91403 | 435 N Roxbury Dr, Suite 315, Beverly Hills, CA 90210 | 2100 North Solar Dr, Suite 202, Oxnard, CA 93036 | 2659 Townsgate Rd, Suite 215, Westlake Village, CA 91361 | 8341 Westminster Blvd, Suite 101, Westminster, CA 92683 | 18501 Gale Ave, Suite 150, City of Industry, CA 91748 | 1510 S. Central Ave, Suite 120, Glendale, CA 91204
Dear Patient:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created several guidelines for doctors to follow to encourage Electronic Patient Communication. A new requirement is the creation of a patient portal for doctor's offices to communicate safely and securely following Health Insurance Portability and Accountability Act of 1996 (HIPAA) guidelines.

Our office has an advanced Electronic Health Record (EHR) system that provides a patient portal called Patient Ally.

Please provide your email below so that we can send you an invite link to create an account.

Thank you for assisting us in fulfilling this important MACRA requirement.

Sincerely,

Dr. Lin
Please print your email address in blocks above in all CAPS.*
example@example.com
We value your privacy. Please let us know your preference.*

I wish to receive emails directly related to my medical care. I agree to allow Michael Lin, MD and his associates to email me information related to my medical care. I agree to allow Michael Lin, MD and his associates to enroll me in Patient Ally.I wish to receive promotional materials to my email addressI do not wish to receive promotional and informational emails regarding news, events and specials from Dr. Lin.
Patient Signature/Parent or Guardian*

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Today's Date*

MonthDayYear
Date
PATIENT INFORMATION
Patient Name*
Date of Birth*

MonthDayYear
Date
Sex*

MF
Marital Status*

SingleMarriedWidowed
Social Security Number
Preferred Language
Mailing Address*
City*
State*
Zip Code*
Home Phone Number
Cell Phone Number
How did you hear about us?

GoogleYelpFaceBookInstagramOther
Referred By
Race*

American Indian or Alaska NativeAsianBlack or African AmericanChineseEuropeanFilipinoEuropean Guamanian or ChamorroJapaneseKoreanOther Asian (ex. Hmong, Laotian, Thai)Oher Pacific Islander (ex. Fijian, Tongan)SamoanVietnameseWhite
Ethnicity*

ChicanoCubanDecline to DiscloseHispanic or LatinoMexicanMexican AmericanMexican, Mexican American, ChicanoNot Hispanic or LatinoUnknown
Pharmacy Information
Preferred Pharmacy
Preferred Pharmacy Phone Number
Preferred Pharmacy Cross Streets
Preferred Pharmacy City
Preferred Pharmacy Zip Code
Allergies
Please describe all allergies and the symptoms:
Medications
Please list your current medications including dose and frequency:
MEDICAL QUESTIONNAIRE
Reason For Visit*
Skin Area Involved
How long has this been affecting your skin?
Please describe your associated symptoms (ie: pain, itch, etc.) and their severity (1-10):
Please list your previous treatments (if applicable) and describe their effectiveness:
Please list any past surgeries and the year they were performed:
Do you use Tobacco?*

Never SmokedFormer SmokerCurrent Smoker
Number of Cigarettes Smoked Per Day (if applicable):
My General Health Is*

PoorFairGoodVery GoodExcellent
Acne Problems

YesNo
Breast Pain / Back Pain / Breast Rash / Breast Surgery

YesNo
Breathing Difficulties (deviated septum, nasal sprays)

YesNo
Cardiovascular Problems or Chest Symptoms

YesNo
Discoloration / Stretch Marks

YesNo
Dry Skin / Itchy Skin

YesNo
Pacemaker / Rhythm Abnormalities

YesNo
Recent Illness / Weight Loss / Weight Gain

YesNo
Vision Problems when Driving or Tired / Droopy Eyelids

YesNo
Diabetes

YesNo
Eczema / Psoriasis

YesNo
Hepatitis C / HIV / AIDS

YesNo
Skin Cancer

YesNo
Stomach Ulcers

YesNo
Tuberculosis

YesNo
Foot Ulcers / Leg Ulcers / Bunions / Hammertoe

YesNo
Knee Pain / Leg Pain

YesNo
Vaginal Bleeding / Heavy Menses / Pelvic Pain

YesNo
Are there any other medical problems we should know about?
Are you currently pregnant?

YesNo
Are you currently breastfeeding?

YesNo
If YES on any of the above, describe the conditions or other medical problems (if applicable):
Family History of Skin Cancer and/or Skin Disease (Please Describe)
PAYMENT POLICY
Thank you for choosing our medical practice. We are committed to providing you the best possible medical care. The following information is provided to avoid any confusion regarding payment for professional medical services. OurInsurance Billing Department will work with you to see that your claim is filed accurately and promptly.
- All Copayments and Deductibles must be collected in full at the time of service if applicable.
- If we are in-network with your insurance plan, we will not discount our services by any further amount after your insurance company has processed your claim and informed us of your responsibility.
- If we are not a contracted provider for your insurance company, we will bill them, as a courtesy, on your behalf.
- If your acount is overdue for more than 180 days after your insurnace has paid, it will be referred to a collection agency. This is done reluctantly, as a last resort, after we have exhausted all efforts for voluntary payment.
- New patients, and those who have no insurance, are required to pay at the time of service with either a credit card or cash. We do not accept personal checks.
Acknowledgement and Authorization

I have read, understood, and agreed to abide by the above payment policy. I understand that charges not covered by insurance company, as well as copayment, deductibles and coinsurances, are my responsibility.

By signing below, you agree to the Terms and Conditions of Advanced Dermatology and Skin Cancer Institute's Payment Policies
Patient/Guardian Signature*

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Patient/Guardian Name*

First NameLast Name
Relationship to the patient*
Office Policy for No Show Patients
No Show Policy:

Please notify our office 48 hours in advance if you are unable to keep your scheduled appointment. If you do not notify us and miss your appointment by not showing up at all, we will require that you pay a $100.00 Missed Appointment Fee before any future appointments.

By signing below, I have read and understood the full Office Policy for No Show Patients.
Patient Signature/Parent or Guardian*

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ACKNOWLEDGMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES

Our office has copies of the HIPAA Notice of Privacy Practices available. Please feel free to get a copy or ask a staff member to hand one to you. I have read/understand the full Notice of Privacy Practices.
Patient Signature/Parent or Guardian*

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NOTICE TO PATIENTS

Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint, go to www.mbc.ca.gov, email: licensecheck@mbc.ca.gov, or call 800-633-2322. By signing below, I acknowledge this notice about the role of the Board.
Patient Signature/Parent or Guardian*

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OPEN PAYMENTS DATABASE

The Open Payments Database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at openpaymentsdata.cms.gov. By signing below, I acknowledge this notice about the Open Payments Database.
Patient Signature/Parent or Guardian*

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Should be Empty:

ADSCI

PATIENT INFORMATION

Pharmacy Information

Allergies

Medications

MEDICAL QUESTIONNAIRE

PAYMENT POLICY

Office Policy for No Show Patients