Bracciano Dermatology 8430 Cooper Creek Blvd | Suite 102
Bracciano Dermatology
8430 Cooper Creek Blvd | Suite 102 | University Park, FL | 34201
Tel: 941-360-2255 | Fax: 941-487-1777
Patient Name _______________________________________Date of Birth __________________________
Address _______________________________________ Home Phone # _________________________
City _________________________State ______Zip________ Social Security # ________________________
Marital Status: Single ___ Married ___ Divorced ___ Widowed___ Legally Separated___
Ethnicity: Caucasian___ Hispanic___ Asian___ African American___ American Indian___ Other____
Gender: Male _____ Female_____ Language Spoken _______________________________________
May we contact you at work? Y/N Tel: (______) _____________________ OK to leave voice mail? Y/N
May we contact you via cell phone? Y/N Tel: (______) ________________ OK to leave voice mail? Y/N
May we contact you via email? Y/N __________________________________________________________
Name of nearest relative _____________________________ Phone # ______________________________
Emergency Contact__________________________________ Phone # ______________________________
Would you like to authorize an individual to receive any of your personal health information? If yes, indicate name and telephone number below:
__________________________________________ ______________________________________
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How did you hear about us? Please check one
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Friend/Relative
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Physician
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LA Fitness Ad
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Church Bulletin/Ad
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ZocDoc
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Phonebook
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Internet
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Other ______________
Name of primary care physician: ____________________________________________
Were you referred by a physician to see Dr. Bracciano? If so, whom? __________________________________
Is your insurance in another person’s name (spouse, parent, etc.)? If so, whom?
Policyholder’s Name: ______________________________________ Policyholder’s Date of Birth:____________
Policyholder’s Social Security Number: ________________________
Bracciano Dermatology
8430 Cooper Creek Blvd | Suite 102 | University Park, FL | 34201
Tel: 941-360-2255 | Fax: 941-487-1777
CONSENT FOR PAYMENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES
Patient Name: ________________________________________ Date of Birth: ____________________
Privacy Protection Agreement and Consent
I consent that photographs may be taken of me or parts of my body, under the following conditions:
The photographs may be taken only with the consent of my provider and under such conditions and at such times as may be approved by him or her. The photographs shall be taken by my provider or by a photographer approved by my provider. The photographs shall be used for medical records and in the opinion of my provider medical research, education, or science will benefit from their use. Such photographs and information relating to my case may be published and republished either separately or in connection with each other in professional journals or medical books, or used for any purpose which my provider may deem proper in the interest of medical education, knowledge, or research; provided, however, that it is specifically understood that in any such publication or use I shall not be identified by name, and reasonable steps shall be taken to preserve my identity. The aforementioned photographs may be modified or retouched in any way that my provider, in his/her discretion, may consider desirable. Decedent Information:
Under the new provisions of HIPAA compliance (eff 9/23/13) health information about a deceased individual is no longer protected 50 years after his/her death. Bracciano Dermatology reserves the right to disclose PHI (Personal Health
Information) regarding the deceased to individuals who were involved in the patient’s care or payment of care, unless contrary to the patient’s prior expressed preference. Medical Records: Bracciano Dermatology will provide you, the patient, with an electronic copy of your medical records upon request. We will also provide copies to a third-party designated by you, if a written and signed request is obtained. Restrictions on disclosure for out-of-pocket (self pay) payments: Bracciano Dermatology will not disclose PHI (Personal Health Information) to your health plan (if applicable) as long as payment for services/procedures is received in full at time of service.
Bracciano Dermatology Financial Policy Acknowledgement
I hereby authorize my current insurance carrier to forward all medical payment(s) on my behalf to Bracciano
Dermatology for any services furnished to me by the physician(s) of this practice. I guarantee payment of all charges incurred for services rendered by Bracciano Dermatology. The amount deemed patient responsibility per your insurance carrier including co-payment, co-insurance deductibles, etc., fee shall be paid in full at time of service. I further authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. This authorization will not be cancelled until further written notice, as this is a lifetime signature of Patient/Guardian. I understand that any amount not covered by my insurance company for ANY reason is my responsibility, and I, being the patient/guarantor, am solely responsible for the payment of any balance on my account. I further understand that if my account should be turned over for collection and/or legal action, I agree to pay for all collection fees including, but not limited to, postage, court costs, collection agency fees, attorney’s fees, and interest from the date of service in the amount of 18% per annum (1.5% per month).
Consent for Self-Pay Procedures and Exams
If you do not have insurance and have requested a procedure or treatment that will be billed directly to you and not an insurance company, please be aware that most dermatology procedures including excisions and biopsies involve two separate components – the actual procedure performed by the dermatologist, and examination of the tissue removed by a pathologist. You will receive two bills for the procedure – one from Bracciano Dermatology, and one from the pathologist.
I understand that the treatment, procedure, or exam that I will have performed today is my financial responsibility. I understand that any tissue that I have removed will be sent for pathologic examination. I also understand that the pathologist/pathology corporation will bill me separately for their pathology services, and that I am responsible for any charges related to this service.
CONSENT FOR PAYMENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES CON’T
ASSIGNMENT OF INSURANCE OR PAYOR BENEFITS
I recognize that I am primarily liable for payment for services rendered. In the event that I am entitled to medical care benefits or insurance of any type whatsoever, I hereby assign those benefits and my rights to the insurance payment to
Bracciano Dermatology. I certify that the insurance or other coverage benefit information supplied by me is correct, in accordance with provider, insurance policies or agreements. I understand that I am responsible for determining which laboratories participate with my insurance plan in regards to pathology specimens, cultures, and blood work.
If my insurance company requires pre-authorization or referrals for services I will receive, I understand that it is my responsibility to obtain the required pre-authorizations or referrals prior to utilizing those
services.
CONSENT TO APPEAL
In the event that my insurance company denies payment for my service; I authorize Bracciano Dermatology to appeal for payment on my behalf.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have had an opportunity to review a copy of Bracciano Dermatology’s Notice of Privacy Practices. I understand that information acquired or created about me by the office of Bracciano Dermatology, will only be disclosed to others for treatment, payment and health care operations as set forth in the Notice of Privacy Practices, or as authorized by me.
YOUR SIGNATURE BELOW SIGNIFIES THAT YOU READ, AGREE, AND UNDERSTAND THE CONTENT, AND AGREE TO OUR
PRIVACY PROTECTION AGREEMENT AND CONSENT, OUR FINANCIAL POLICY AND YOUR RESPONSBILITY REGARDING
CHARGES INCURRED IN THIS OFFICE.
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STAFF INITIALS PATIENT/GUARDIAN SIGNATURE
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DATE
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DATE
Bracciano Dermatology
8430 Cooper Creek Blvd | Suite 102 | University Park, FL | 34201
Tel: 941-360-2255 | Fax: 941-487-1777
Patient Name _______________________________
Past Medical History
(check all that apply)
Anxiety
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Hypertension
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Arthritis
Asthma
Atrial Fibrillation (Irregular Heartbeat)
Bone Marrow Transplantation
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HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
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Benign Prostate Hyperplasia
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
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Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
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Diabetes
End Stage Renal Disease
GERD
Hearing Loss
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Stroke
Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
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Hepatitis
Past Surgical History
Type of surgery Date
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Bracciano Dermatology
8430 Cooper Creek Blvd | Suite 102 | University Park, FL | 34201
Tel: 941-360-2255 | Fax: 941-487-1777
Patient Name _______________________________
Medication List:
Date _____________________
Name of Medication
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Allergy List:
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Date Started Dosage Frequency
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