New Patient Medical Form

Medical Patient Information

Name *

First

Middle

Last

Cell Phone *

Alt Phone/Home Phone

Email *

Address *

Apt #

City *

State *

Zip Code *

Employer/School

Work/School Phone

Date of Birth *

Sex *

Marital Status

SSN *

Race

Ethnicity

Language *

How were you referred? *

Responsible Party Name

Responsible Party Relationship to Patient

If patient is minor:

Mother
Father
Legal Guardian

Date of Birth

SSN

Home Phone

Work Phone

Address

Primary Insurance Company *

Group Number

Policy Number

Subscriber

Subscriber DOB

Relation to patient

Address (if different from patient)

Secondary Insurance Company

Group Number

Policy Number

Subscriber

Subscriber DOB

Relation to patient

Address (if different from patient)

May we leave personal information on your answering machine? *

Text to your cell phone? *

Send to your email address *

I acknowledge that Prism Dermatology, PLLC may communicate with me via US mail, home or cell phone. *

Initials

I request for an alternative method of communication such as alternative address or work phone number.

Initials

Alternative method

Alternative address, email, or phone number

I request to be web enabled through Modernizing Medicine for secure access to information related to my care. I will be emailed the instructions and password for web access. *

Do you have an Advanced Directive (Living Will)? *

If YES, does anyone make medical decisions on your behalf?

Decision Maker Name

Phone

ASSIGNMENT OF INSURANCE AND FINANCIAL RESPONSIBILITY I do, hereby authorize payment of my insurance benefits, including authorized Medicare benefits, basic and major medical for the services I receive, to be made directly to Prism Dermatology, PLLC. *

Initial

CONSENT FOR MEDICAL SERVICES I authorize Prism Dermatology, PLLC to render treatment to me or my dependents for dermatological care or medical procedures as deemed medically necessary for treatment as indicated. *

Initial

REFERRALS/AUTHORIZATIONS I understand that if my insurance requires a referral or an authorization, I am responsible for obtaining the referral prior to my visit. If I do not have a referral or authorization at the time of my visit, I may be rescheduled or sign a waiver of financial responsibility. In such case I understand that full payment will be required at the time of service. *

Initial

FINANCIAL RESPONSIBILITY I understand that although Prism Dermatology, PLLC will file a claim to my insurance plan(s), I am expected to pay my copayment, coinsurance, deductible and non-covered services amounts at the time services are rendered. I acknowledge that Prism Dermatology, PLLC does not guarantee payment of my claim by my insurance plan and that it is my responsibility to know the provisions of my insurance. Not all procedures are deemed “Medical Necessity” by insurance carriers and can be considered cosmetic. For example-Skin tag removal, correction of dark spots, yearly skin cancer screenings without specific areas of concern, would not be a covered service. I understand that I would be responsible for payment of such services. I am ultimately responsible for any unpaid balance or non-covered service. I agree to pay all costs of collecting, securing or attempting to collect or secure payment, including reasonable attorney fees or collection agency fees. I also understand that any prior unpaid balances on my account must be paid in full before being seen by a provider. If my prior balance cannot be paid in full, I will speak with a financial counselor at Prism Dermatology, PLLC to make a payment arrangement before services can be rendered. I also understand that if Prism Dermatology, PLLC does not participate with my insurance plan that I will be expected to pay in full for my services. And it is my responsibility to know if Prism Dermatology, PLLC is in network with my insurance plan. I understand that payments to Prism Dermatology, PLLC can be made by cash, checks and all major credit cards. I also acknowledge that returned checks will be subject to a non-sufficient fund fee of $25.00. *

Initial

COSMETIC SERVICES Cosmetic services are not a covered benefit under insurance plans. I understand that to make an appointment for cosmetic services, I will be expected to pay half of the service as a down payment and be expected to pay the remaining balance when services are rendered. *

Initial

PATIENT RESPONSIBILITY I understand that due to Federal (red flag) rules that Prism Dermatology, PLLC is prevented from filing to my insurance without proof of identification. I will be expected to present a photo ID and insurance card(s) at every office visit. I will also update any changes to my addresses, telephone numbers and insurance if they have changed since my last visit and I understand that I will be asked to update my demographics and signatures annually. *

Initial

MISSED APPOINTMENTS It is my responsibility to notify Prism Dermatology, PLLC at least 48 hours prior to my appointment if I am unable to keep the appointment. I acknowledge that if I miss two appointments without sufficient notification that I will be charged a $50 fee. If I miss three appointments without sufficient notification, I will be dismissed from the practice for non-compliance. *

Initial

PRIVACY POLICY NOTICES I have been offered a copy of Prism Dermatology, PLLC’s Notice of Privacy Policies that details how my personal health information may be used, disclosed and my rights as permitted by federal law. As well I understand that this notice is posted for my benefit in the reception areas and on the website of Prism Dermatology, PLLC. *

Initial

ePRESCRIBING CONSENT I acknowledge that Prism Dermatology, PLLC utilizes electronic health records and will transmit my prescriptions electronically as permitted to the pharmacy that I designate as my pharmacy provider. To enable electronic prescriptions to my pharmacy, I grant Prism Dermatology, PLLC my permission to access my medication history to view current and past prescription information. *

Initial

LAB SERVICES I am aware that my laboratory/pathology services may not be billed from Prism Dermatology, PLLC. I will receive a separate statement from the lab or pathologist. In addition it is my responsibility to contact my insurance plan to determine what laboratory is in network for my plan. *

Initial

Patient/Guardian Signature *

Initial

Date *

Month/Date/Year

Witness

If applicable

REASON FOR TODAY'S VISIT *

Pharmacy *

Pharmacy Phone

Pharmacy Address/Zip Code

Personal Medical History (such as high-blood pressure, diabetes, etc.) *

Major Surgery/Hospitalization *

Current Medications (Dose and Frequency) *

Personal History of Skin Cancer *

If yes, give dates and location on body

Skin Cancer Types

Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
Other

Family History of Skin Cancer

Basal Cell Carcinoma
Squamous Cell
Melanoma
Other

If you have a family history of skin cancer, please indicated their relation to you (such as mother, sister etc.)

Do you smoke tobacco? *

Did you previously smoke tobacco? *

History of tanning bed use? *

Did you have an influenza (flu) vaccine? *

Do you have a pacemaker/defribulator? *

Do you have an artificial joint/heart valve? *

Do you take antibiotics prior to procedures?

If 65 years old or older, have you had a Pneumococcal Vaccination?

Occupation *

Allergies: (Medication/Food) *

List all known allergies

Allergic to the following:

Iodine
Latex
Adhesive
Nickel or Metal Allergy

Constitutional Symptoms

Fever or Chills
Night Sweats
Unintentional Weight Loss

Allergic/ Immunologic Respiratory

Immunosuppression
Hay Fever Cough
Shortness of Breath
Wheezing

Hematologic/ Lymphatic

Problems with bleeding
Other

Endocrine

Thyroid Problems

ENT/ Mouth

Sore Throat
Other

Integumentary

Problems with Healing
Problems with Scarring (Hypertrophic or Keloid)
Rash

Eyes

Blurry Vision

Gastrointestinal

Abdominal Pain
Bloody Stool
Bloody Urine

Musculoskeletal

Joint Aches
Muscle Weakness
Neck Stiffness

Neurological

Headaches
Seizures

Cardiovascular

Chest Pain

Psychiatric

Anxiety
Depression

Signature of Patient *

Initial

Date *

Month/Date/Year

Phone

Phone: 817-329-1350

Get Directions

Email Us

Patient Portal

Pay Your Bill

Phone: 817-329-1350

Get Direction

Email Us

Patient Portal

Pay Your Bill

Make An Appointment Today

Phone: 817-329-1350
Fax: 817-329-1366

Patients

Shop

© 2023 Prism Dermatology

Phone: 817-329-1350

Get Directions

Email Us

Patient Portal

Pay Your Bill

Phone: 817-329-1350

Get Direction

Email Us

Patient Portal

Pay Your Bill

New Patient Medical Form

Make An Appointment Today

Phone: 817-329-1350 Fax: 817-329-1366

Patients

Shop

© 2023 Prism Dermatology

Phone: 817-329-1350
Fax: 817-329-1366