P A T I E N T   R E G I S T R A T I O N   

Name: ____________________________________________________________________________________     FIRST        MIDDLE          LAST 

Date of Birth: _______________    Social Security Number: __________________   Gender: _______________ 

 

Mailing Address:____________________________________________________________________________       STREET          CITY      STATE    ZIP 

 

Cell Phone: _____________________________    Home Phone: _______________________________ Which number is primary?    CELL or HOME               Are we allowed to leave detailed messages? YES or NO 

E‐Mail Address: _____________________________________________________________________________ Providing your e‐mail will opt you in for e‐mailed appointment reminders and office promotions/updates 

Guarantor Name: ________________ Guarantor DOB: ___________ Relationship to Patient: ______________ 

Employer: _________________________________________  Employer Phone: _________________________ 

 

Marital Status: (circle)   Single    Married  Separated  Divorced  Widowed 

 

Race: (circle)    American Indian        Alaska Native        Native Hawaiian        African American        White 

      Asian        Pacific Islander        Other: __________________________ 

 

Ethnicity: (circle)  Not Hispanic or Latino        Hispanic/Latino        Unknown        Decline to Specify 

 

Language: (circle)        English        Spanish        Other: __________________________ 

 

If you change insurance carriers or you are issued a new card, it is your responsibility to provide the new card to our office.  

 

After your visit today, you will have access to an online Patient Portal where your complete medical record can be viewed.  You may 

obtain your log‐in information at your visit from staff or by e‐mailing us at cderm@cumberlandderm.com.  If you provide your e‐mail 

address, we can automatically do this for you. 

 

Please review and sign:  I authorize Cumberland Dermatology for treatment.  I also authorize the release of any information acquired 

in  the  course of  the  examination  and  treatment  to  secure payment of  claims  and benefits.    I understand  that  the Cumberland 

Dermatology policy requires payment at time of service.  I authorize payment directly from my insurance company (if applicable) to 

Cumberland Dermatology.    I agree to be responsible for any deductibles, copays, coinsurances and services rendered that are not 

covered by my insurance plan.  

 

____________________________________________________________________________________________________________ 

Signature of Patient or Patient Representative          Date 

01.29.2019

Cumberland Dermatology 

O F F I C E   F I N A N C I A L   P O L I C Y  

We would like to share the following policies with you so that you understand your responsibility regarding the 

charges  for  services  rendered  to  you  by  this  office.    It  is  necessary  that  you  provide  accurate  and  updated 

information when you are  seen  for  services  that  can be billed  to your  insurance.    If  your  insurance  requires a 

referral or prior authorization, it is your responsibility to make sure we have that from your doctor or insurance 

company.  This information must be in this office prior to your being seen.  If you arrive for an appointment and 

have an insurance that requires such paperwork, you will not be seen if it is not present. 

On the day of your appointment, you will be responsible for the following: 

o Co‐Payments, Co‐Insurance, Insurance Deductibles 

o Charges for non‐covered services or cosmetic procedures 

o Payment in full if you are Self‐Pay or have an Out of Network insurance 

If your deductible has not been met or you have an out of network insurance carrier, we will collect payment 

in full and process a refund, if applicable, once the claim processes.  

It is your responsibility to make sure your primary insurance is aware of your secondary insurance and 

that it is set up to cross over automatically.  WE CAN NOT DO THIS FOR YOU.   

All  charges are  your  responsibility whether  your  insurance  company pays or not.   Not all  services are  a 

covered  benefit  in  all  contracts.    It  is  your  responsibility  to  provide  accurate  and  current  insurance 

information and to keep your file updated with that information.  If you fail to provide correct insurance 

information at the time of your appointment and it results in a claim denial, you are responsible for payment 

of these services.    If you attempt to provide insurance information at a  later date,  it may or may not be 

accepted.  Most insurances have a time limit of filing claims.  If we are unable to collect from your primary 

or secondary insurance within three (3) months the balance will be turned over to you the patient.   

Billing statements are mailed after your claim processes and the balance is due within 30 days of receipt.   

Unpaid balances will receive a late notice and will be turned over to a collection agency if not paid within 30 

days of the late notice.  Once an account is turned over to collections, all communications will be with the 

collection agency.  After your balance is paid with the collection agency, you will be required to pay in full at 

every visit thereafter.  Once your insurance processes, we will issue a refund for any credit on the account.  

Patients who are in collection status and do not bring their account current may be discharged via certified 

letter from Cumberland Dermatology with availability only for emergency care 30 days following dismissal.  

Accounts sent to collection will be assessed a fee equal to 20% of the balance due. 

We will not accept insurance cards that have been altered or tampered with in any way.  

We will ask to scan and verify your  insurance cards once a year.    If you have changes to your  insurance 

coverage you must inform the registration staff and provide a copy of the new card. 

We accept the following forms of payment:  Cash, Check, Visa, MasterCard, Discover, American Express and 

Care Credit.  Returned Checks will be subject to a $25.00 fee which will be added to the balance due.  Once 

a patient balance is determined, a statement will be mailed to the address which was provided to us.  

Should you require a surgical procedure, you will be given a quote  for  these services  in  relation to your 

insurance coverage. It is your responsibility to determine payment arrangements as this will be collected on 

the day of your procedure.   

You will be asked to sign this document every three (3) years.   

 

________________________________    ________________________________ 

      PATIENT SIGNATURE            DATE 

First: ___________________________ Middle Initial: ________ Last: __________________________ Jr/Sr: ______

Date of Birth: ____________________ Pharmacy: _____________________

Primary Care Doctor: ______________________ Referring Doctor: _________________

I authorize Cumberland Dermatology to electronically import my medications (circle) Yes No

Do you have a history of: Y N Y N Y N

Arthritis Colon: (Colectomy) Colon Cancer Resection Prostate (Prostatectomy)

COPD Rectum: APR (Abdominoperineal resection) Spleen (Splenectomy)

Depression Breast: Breast Biopsy Skin: Skin Biopsy

Diabetes Prostate (Prostatectomy): Prostate Biopsy Liver Resection/Hepatectomy

End Stage Renal Disease Gallbladder (Cholecystectomy) Kidney: Nephrectomy

HIV/AIDS (Human Immunodeficiency virus) Bladder (Complete Cystectomy) Testicles (Orchiectomy)

High Cholesterol (Hypercholesterolemia) Heart: Coronary Artery Bypass Surgery Total Hip replacement-Left

Leukemia Ovaries (Oophorectomy): Ovarian Cyst Total knee replacement-Left

Lymphoma Colon: (Colectomy) Diverticulitis Total Hip replacement-Right

Colon Cancer (Malignant tumor of colon) Kidney: Kidney Transplant Total Knee replacement-Right

Anxiety Skin: Basal Cell Carcinoma Liver Shunt (TIPS)

Asthma Skin: Melanoma Heart: Heart Transplant

Atrial fibrillation (Irregular heartbeat) Skin: Squamous Cell Carcinoma Liver: Liver Transplant

Enlarged Prostate (BPH) Ovaries: Tubal Ligation History OTHER:

Pacemaker HearBiologic Valve Replacement/Graft OTHER:

Stroke (Cerebellar stroke) Appendix (Appendicetomy) OTHER:

Seizures Prostate (Prostatectomy): TURP OTHER:

Coronary Artery Disease Uterus (Hysterectomy) OTHER:

Elevated Blood Pressure Colon:(Colectomy) Inflammatory Bowel Disease OTHER:

GERD (Acid reflux) Kidney: Kidney Biopsy OTHER:

Hearing Loss Kidney: Kidney Stone Removal OTHER:

Hyperthyroidism (overactive thyroid) Rectum: Lower Anterior Resection OTHER:

Hypothyroidism (underactive thyroid) Breast: Lumpectomy, Left OTHER:

Hepatitis Breast Lumpectomy, Right OTHER:

Lung Cancer Breast Mastectomy Left OTHER:

Breast Cancer Breast Mastectomy Right OTHER:

Prostate Cancer Heart: Mechanical Valve Replacement OTHER:

Radiation therapy treatment Ovaries (Oophorectomy) OTHER:

Bone Marrow Transplant (BMT) Pancreas: Pancreatectomy OTHER:

Other: Heart: PTCA OTHER:

Do you have a history of: Y N Y N Y N

Acne Eczema Family History of Melanoma

Actinic Keratosis Hay Fever / Allergies If Yes, Which Relative?

Asthma Melanoma Tanning Salon

Basal Cell Skin Cancer Psoriasis Do You Wear Sunscreen?

Dry Skin Scalp Itchy/Flaky If Yes, What SPF? (circle)

Poison Ivy (Contact Dermatitis) Squamous Cell Skin Cancer

Precancerous Moles (Dysplastic nevus) Sunburn-Blistering Other:

CUMBERLAND DERMATOLOGY, P.C.

Medical, Social, Family History and Review of Systems

Emergency Contact: ______________________ Phone #: _________________ Relation: _____________________

***PLEASE CONTINUE ON REVERSE SIDE***

Past Medical History: Please Check Yes or No Past Surgical History: Please Check Yes or No

Skin Disease History: Please Check Yes or No

SPF 15 SPF 30 SPF 45

Name Dose Frequency Route

Review of Systems: (Past Several Months) Please Check Yes or NoY N Y N Y N

Artifical Joints within past 2 years Blurry Vision Thyroid Problems

Pregnancy or planning a pregnancy Chest Pain Unintentional Weight Loss

Yeast Infections with antibiotics Cough Wheezing

GI Upset with antibiotics Depression Pacemaker

Problems with Bleeding Fever or Chills Defibrillator

Problems with Healing Headaches Artifical Heart Valve

Problems with Scarring (Keloid) Hay fever Premedication

Immunosupression Joint Aches Allergy to Adhesive

Changing Mole Muscle Weakness Allergy to Topical Ointment

Rash Neck Stiffness Blood Thinners

Abdominal Pain Night Sweats Allergy to Lidocaine

Anxiety Seizures Rapid Heart Beat with Epinephrine

Blood Stool Shortness of Breath Other:

Bloody Urine Sore Throat None of the Above

Y N

Do you drink alcohol? Smoking Status: (circle one)

If Yes, Number of Drinks Per Day

If former smoker, date you stopped?

PRESCRIPTIONS / OVER-THE-COUNTER MEDICATIONS: ALLERGIES TO MEDICATIONS:

CUMBERLAND DERMATOLOGY, P.C.

Medical, Social, Family History and Review of Systems

I certify that I have read and understand the above questions and acknowledge that questions have been

DATE OF RECENT PNEUMONIA VACCINATION:

DATE OF RECENT FLU VACCINATION:

date signed and will require a new form be completed.

How many times in the past year haveyou had 5 or more drinks in a day (formen), or 4 or more drinks in a day (forwomen) or any adult older than 65?

Social History: Please Check Yes or No

Never Smoker Current Smoker Former Smoker

If current smoker, how many packs per day?

Patient's Signature ______________________________________ Date _________________________________

answered to the best of my knowledge. This health form will expire three (3) years from

PRACTICE INFORMATION

YOUR APPOINTMENT Your time is important to us. Your appointment was scheduled based on the reason you gave us when you scheduled. If you have additional problems or need to discuss other concerns with your provider, we will have to schedule a separate appointment to address these problems / concerns. This will allow us to be considerate of other patient appointments.

CONFIRMING YOUR APPOINTMENT Due to the high demand for dermatology appointments and frequent no-shows, we do require you to confirm your appointment two to three days prior to your scheduled visit. If an appointment is not confirmed, it will be canceled. As a courtesy, we work to confirm your appointments by using e-mail, text messaging and/or a phone call from our online appointment scheduling software. We know how easy it is to forget an appointment you booked months ago. With our current system you have the option of the following:

confirm your appointment from the link provided in the e-mail; confirm your appointment by responding with the number 1 to the text; confirm your appointment by phone using the appropriate selection prompts; call our office at #931-484-6061 to cancel, makes changes, or to confirm directly

Please understand that it is your responsibility to remember your appointment dates and times. Not receiving an electronic notification of your appointments from us is not sufficient reason to miss an appointment.

LATE ARRIVALS Out of respect for other patients arriving on time, if you arrive more than 15 minutes late, you may be asked to reschedule. However, arriving less than 15 minutes late DOES NOT guarantee that you will be seen. It is at the discretion of your health care provider whether you can be worked back in to the schedule. If you have not signed in within five (5) minutes of your appointment time, someone from the office will call to verify if you are still planning on keeping your appointment.

YOUR PRESCRIPTIONS Unless you request a written prescription to take with you after your visit, prescriptions are sent electronically to your pharmacy. This often means that your prescription will not be ready for pickup until the end of the day. We strongly suggest you call your pharmacy to make sure your prescriptions are ready before going to pick them up.

Insurance companies often change their list of "preferred drugs". We try very hard to keep current with these changes. However, you may find that your insurance company has rejected your prescription because it is not on their "preferred list". Again, we suggest you call your pharmacy to make sure your prescription(s) are ready before going to pick them up. If your prescription is rejected by your insurance because it is not on their "preferred list", additional time will be required for approval of a substitute medication.

CANCELLATION / NO-SHOW POLICY We respectfully ask for 24 hours’ notice if you will be unable to keep an appointment. If you have more than three (3) no-show occurrences, you may be discharged from the practice. PROCEDURES: If you no show or cancel an appointment for a procedure with less than a 24 hours’ notice (including Mohs, BOTOX, fillers, Microneedling, excisions, ED&C or LN2) you will be subject to a $50.00 non-refundable cancellation fee that must be paid prior to rescheduling. If you miss two procedures without proper notice within a 12-month period, you may be discharged from the practice for non-compliance.

PAYMENTS DUE AT TIME OF SERVICE Co-pays, co-insurance, deductibles and payment for cosmetic services rendered are expected at time of visit.

CONSENT TO TREAT MINORS Minors, persons under the age of 18, must be accompanied by a parent or legal guardian for all appointments.

CONSENT TO LEAVE MESSAGES / PATIENT ACCESS By completing the consent below, you are allowing the providers and staff of Cumberland Dermatology to leave a message on an answering machine, voicemail or with a specified individual (per your HIPAA release). By signing, you are also consenting to the mailing, e-mailing, texting or faxing of any results or appointment information to you or your primary care physician or another physician involved in your care. You may view your medical record by using our secure patient portal. If you provide an e-mail address, we will send you an activation link to gain entry.

Patient Name (please print): DOB: _______________________

Patient Signature: ______________________________________________________________

Signature of Patient or Patient Representative

Print Name of Patient or Patient Representative Patient Date of Birth

Today's Date

Individual Refused to sign Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgements

Other (Please Specify) _______________________________________________________________

OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgementcould not be obtained because:

I authorize the disclosure of information regarding my billing, condition, treatment and prognosis to the following individual(s):

This authorization shall be in force and effect for thirty-six (36) months at which time this authorization expires.

I understand that I have the right to revoke this authorization, in writing, at any time prior to the planned expiration date.

Phone: __________________________________

Phone: __________________________________

KENDALL ANNE MORRISON, MD • JUSTIN BELL, NP-C • BROOKE HUFF, PA-C • JESSICA ROTOLO, PA-C

Name: __________________________________ Relationship: __________________________________

Name: __________________________________ Relationship: __________________________________

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have read and understand Cumberland Dermatology's Notice of Privacy Practices. I acknowledge that I may request and will be provided a copy at any time from the office. I also understand that I am

able to take the copy with me that I read prior to signing this notice.

* You May Refuse to Sign This Acknowledgement *

Who are we allowed to talk to about your medical treatment? TELL US HERE

Effective Date: April 14, 2003

Updated: 06/01/2013

Ways in Which We May Use and Disclose Your Protected Health Information:

Other Ways We May Use and Disclose Your Protected Health Information:

As Required by Law. We will use and disclose your protected health information when required to by federal, state, or

local law. You will be notified of any such disclosures.

To Avert a Serious Threat to Public Health or Safety. We will use and disclose your protected health information to a

public health authority that is permitted to collect or receive the information for the purpose of controlling disease, injury, or

disability. If directed by that health authority, we will also disclose your health information to a foreign government agency

that is collaborating with the public health authority.

Worker's Compensation. We will use and disclose your protected health information for worker's compensation or

similar programs that provide benefits for work-related injuries or illness.

Inmates. We will use and disclose your protected health information to a correctional institution or law enforcement

official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This

information would be necessary for the institution to provide you with health care; to protect the health and safety of

others; or for the safety and security of the correctional institution.

Payment. We will use and disclose your protected health information to obtain payment for the health care services we

provide you. For example -- we may include information with a bill to a third-party payer that identifies you, your diagnosis,

procedures performed, and supplies used in rendering the service.

Research. We will use and disclose your protected health information for research provided the research has been

approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the

privacy of your health information.

Health Care Operations. We will use and disclose your protected health information to support the business activities of

our practice. For example -- we may use medical information about you to review and evaluate our treatment and services

or to evaluate our staff's performance while caring for you. In addition, we may disclose your health information to third

party business associates who perform billing, consulting, or transcription services for our practice.

Appointment Reminders. We will use and disclose your protected health information to contact you as a reminder about

scheduled appointments or treatment.

Treatment Alternatives. We will use and disclose your protected health information to tell you about or to recommend

possible alternative treatments or options that may be of interest to you.

Others Involved in Your Care. We will use and disclose your protected health information to a family member, a relative,

a close friend, or any other person you identify that is involved in your medical care or payment for care.

CUMBERLAND DERMATOLOGY, P.C.

Notice of Health Information Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can

get access to this information. Please review it carefully.

We are required by law to provide you with this notice that explains our privacy practices with regard to your medical

information and how we may use and disclose your protected health information for treatment, payment, and for health

care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the

privacy of your protected health information and we also describe them in this notice.

The following paragraphs describe different ways that we use and disclose your protected health information. We have

provided an example for each category, but these examples are not meant to be exhaustive. We assure you that all of the

ways we are permitted to use and disclose your health information fall within one of these categories.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health

care and any related services. We will also disclose your health information to other physicians who may be treating you.

Additionally, we may, from time to time, disclose your health information to another physician who we have requested to be

involved in your care. For example -- we would disclose your health information to a specialist to whom we have referred

you for a diagnosis to help in your treatment.

(PATIENT COPY)

Your Health Information Rights

Uses or Disclosures Not Covered

For More Information

29 Taylor Ave, Suite 101, Crossville, TN 38555

303 N Oak Ave, Cookeville, TN 38501

Request Amendment. You have the right to request that we amend your medical information if you feel that it is

incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information

is incomplete or inaccurate and your reasoning that supports your request. We are permitted to deny your request if it is

not in writing or does not include a reason to support the request. We may also deny your request if:

(1) the information was not created by us, or the person who created it is no longer available to make the amendment;

(2) the information is not part of the record which you are permitted to inspect and copy;

(3) the information is not part of the designated record set kept by this practice; or if it is the opinion of the health care

provider that the information is not accurate and complete.

Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your medical

information for treatment, payment, or health care operations. For example -- you could request that we not disclose

information about a prior treatment to a family member or friend who may be involved in your care or payment for care.

Your request may be made in writing to our practice manager. We are not required to agree to your request if we feel it is

in your best interest to use or disclose that information. However, if we do agree, we will comply with your request unless

that information is needed for emergency treatment.

An Accounting of Disclosures. You have the right to request a list of the disclosures of your health information we have

made outside of our practice that were not for treatment, payment, or health care operations. Your request must be made

in writing and must state the time period for the requested information. You may not request information for any dates prior

to April 14, 2003 (the compliance date for the federal regulation) nor for a period of time greater than six years (our legal

obligation to retain information).

File a Complaint. If you believe we have violated your medical information privacy rights, you have the right to file a

complaint with our practice manager or directly to the Secretary of Health and Human Services. To file a complaint with

our manager, you must make it in writing within 180 days of the suspected violation. Provide as must detail as you can

about the suspected violation and send it to Cumberland Dermatology, 29 Taylor Avenue, Suite 101, Crossville, TN

38555. You should know that there would be no retaliation for your filing a complaint.

Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made

with your written authorization. You may revoke such authorization, in writing, at any time and we will no longer disclose

health information about you for the reason stated in your written authorization. Disclosures made in reliance on the

authorization prior to the revocation are not affected by the revocation.

CUMBERLAND DERMATOLOGY

If you have questions or would like additional information, you may contact our practice manager at (931) 484-6061.

CUMBERLAND DERMATOLOGY, P.C.

Although your health record is the physical property of the health care practitioner or facility that compiled it, the

information belongs to you. You have the right to:

A Paper Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a

copy by asking our receptionist at your visit or by calling and asking us to mail you a copy.

Request Confidential Communications. You have the right to request how we communicate with you to preserve your

privacy. For example -- you may request that we call you only at your work number, by mail at a special address or postal

box. Your request must be made in writing and must specify how or where we are able to contact you. We will

accommodate all reasonable requests.

Inspect and Copy. You have the right to inspect and copy the protected health information that we maintain about you in

our designated record set for as long as we maintain that information. This designated record set includes your medical

and billing records as well as any other records we use for making decisions about you. Any psychotherapy notes that

may have been included in records we received about you are not available for your inspection or copying by law. We may

charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

If you wish to inspect or copy your medical information, you must submit your request in writing to our practice manager at

Cumberland Dermatology, 29 Taylor Avenue, Suite 101. Crossville, TN 38555. You may mail in your request, or bring it to

our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the

information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.

AASYMMETRY

THE ABCDEs OF MELANOMA

Melanoma is the deadliest form of skin cancer. However, when detected early, melanoma can be effectively treated. You can identify the warning signs of melanoma by looking for the following:

One half is unlike the other half.

DDIAMETER

6mm

While melanomas are usually greater than 6mm (the size of a pencil eraser) when diagnosed, they can

BBORDER

Irregular, scalloped or poorly defined border.

COLORCOLOR

C Varied from one area to another; shades of tan and brown, black; some-times white, red or blue.

EEVOLVING

A mole or skin lesion that looks different from the rest or is changing in size, shape or color.

Example:

Precancerous Growth

Skin Cancer

Actinic Keratoses (AK):Dry, scaly patch or spots.

Basal Cell Carcinoma (BCC): Flesh-colored, pearl-like bumps or a pinkish patch of skin.

Squamous Cell Carcinoma (SCC):Red firm bumps, scaly patches or sores that heal and then return.

How to check your spots SKIN CANCER SELF-EXAMINATION

Checking your skin means taking note of all the spots on your body, from moles to freckles to age spots. Ask someone for help when checking your skin, especially in hard to see places.

What you’re looking for on your skin

Download the Academy’s Body Mole Map

at spotme.org to record your spots during

your next skin self-exam.

Examine body front and back in mirror, then right and left sides, arms

Bend elbows, look carefully at forearms, back of upper arms, and palms.

Finally, look at backs of legs and feet, spaces between toes, and soles.

Examine back of neck and scalp with a hand mirror. Part hair for a closer look at your scalp.

Check back and buttocks with a hand mirror.

2

3

5

1

4

• Learn more about skin cancer

• Find a dermatologist in your area

Visit spotme.org to:

16-309-CMM

OTHER TYPES OF SKIN CANCER

When checking your skin, please look for signs of these other suspicious spots.

Live.

Detect.

© 2016 American Academy of Dermatology. All rights

If you find any spots on your skin that are changing, itching, or

bleeding, make an appointment to see a board-certified dermatologist.

WHEN CAUGHT EARLY, SKIN CANCER

IS HIGHLY TREATABLE