IDAHO SKIN INSTITUTE MEDICAL HISTORY History and Intake Form

Referring/Primary Care Physician_: _____________________ _

NAME: DATE OF BIRTH: DATE: --------------- ------------ -------

Past Medical History: (please check all that apply) Anxiety Artificial joints Asthma Atrial fibrillation

Arthritis

BPH (Benign Prostatic Hyperplasia) Bone Marrow Transplantation Breast Cancer Colon Cancer COPD (Emphysema) Coronary Artery Disease Depression

Diabetes End Stage Renal Disease GERO (Acid reflux)

Hearing Loss Hepatitis Hypertension HIV/AIDS

Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia

Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement None

Other _____________________________________ _

Past Surgical History: (please check all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed

Coronary Artery Bypass PTCA Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Knee Replacement (Right, Left, Bilateral) Hip Replacement(Right, Left, Bilateral) Joint Replacement (within last 2years) Kidney Biopsy Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant

Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Cancer Surgery Melanoma Surgery Spleen Removed Testicles Removed (Right, Left, Bilateral) None

Other _____________________________________ _

Skin Disease History: (please check all that apply)

Acne Dry Skin

Actinic Keratosis

Asthma

Basal Cell Skin Cancer

Blistering Sunburns

Other

Eczema

Flaking or Itchy Scalp

Hay Fever/Allergies

Melanoma

Poison Ivy

Precancerous Moles

Psoriasis

Squamous Cell Skin Cancer

None

-------------------------------------

Women ONLY: (please check all that apply)

Currently Pregnant Ovaries Removed:

Breast Feeding Endometriosis

Hysterectomy: Ovarian Cancer

Fibroids Ovarian Cyst

Uterine Cancer

Other

Oral Contraception

Tubal Ligation

Post-Menopausal

Frequent Yeast Infection

--------------------------------------

Yes No

HeadachesDepression

loss

Cough

healing

AnxietyAnemia

Other

Alert Yes NoPacemaker/De�ibrillatorDe�ibrillator

HIV

CoumadinPlavix

Immunosuppressionradiation

Other

(please check all that apply)

IDAHO SKIN INSTITUTE 147 W Chubbuck Rd∙Chubbuck, ID 83202

Clinic: 208-238-SKIN (7546)∙Fax: 208-237-9643

PATIENT INFORMATION Name (Last, First, Initial) Date

Social Security Number Date of Birth Sex [ M ] [ F ]

Address City, State, Zip

Race: [ ]-White [ ]-Hispanic [ ]-Black [ ]-American Indian [ ]-Asian Preferred Language: [ ] English or Other___________

Marital Status: [ ]-Married [ ]-Single [ ]-Other [ ]-Widow [ ]-Separated [ ]-Divorced

Referred By

Home Phone Work Phone Cell Phone

E-mail Address:

Employment Status: [ ]-Full Time [ ]-Part Time [ ]-Retired [ ]-Unemployed [ ]-Full Time Student [ ]-Part Time Student

Employed By: Employer Phone:

Spouse/Parent’s Name Date of Birth

Emergency Contact Relationship Phone# (not living with you)

PRIMARY RESPONSIBLE PARTY (Statements will be sent to this person)

Name (Last, First, Initial) Relationship

Address City, State, Zip

Home Phone Work Phone Cell Phone

*Social Security Number Sex Date of Birth

Employed By: Employer Phone: .

INSURANCE INFORMATION We are contracted with: Blue Cross, Blue Shield, DMBA, IHC, Medicaid, Medicare, SIPHO/MRI, Beech Street, IPN, and UPREHS

For accurate billing to insurance, we will request a copy of your insurance card for our files.

Primary Insurance Policy Holder’s Name

Policy Holder’s Date of Birth Sex Employer

Group #: Policy#

Secondary Insurance Policy Holder’s Name

Policy Holder’s Date of Birth Sex Employer

Group #: Policy #:

ASSIGNMENT AND RELEASE: Please initial next to the line that is appropriate

Initial Below

NON MEDICARE: I hereby assign my insurance benefits to be paid directly to the physician. I understand that I am financially

responsible for any non-covered services. I authorize the physician to release any information required to process my claim.

MEDICARE: I request that payment of authorized Medicare benefits be made either to me or on my behalf to Idaho Skin Institute for

any services furnished me by that practice. I authorize any holder of medical information about me to release to the Centers for Medicare and

Medicaid Services, formally the Health Care Financing Administration and its agents any information needed to determine these benefits or the

benefits payable for related services.

AUTHORIZATION/ACKNOWLEGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, (name of patient) , acknowledge and agree that I have read a copy of

Idaho Skin Institute’s Notice of Privacy Practices.

Patient Signature Date

Patient Legal Representative (if applicable) Date

Print Name of Legal Representative Date

Thank you for choosing The Idaho Skin Institute for your dermatology health care provider.

The following is a statement of our Financial Policy: IF YOU HAVE HEALTH INSURANCE COVERAGE:

You are responsible to supply us with correct current

insurance information.

Please notify us of any change in your address or

telephone number.

All copay’s are due at the time of service.

Referrals are your responsibility and must be current

prior to your visit.

Your estimated portion, including any deductibles, will

be expected at the time of service (our business

office will notify you in advance if this is required).

You may not receive a self-pay discount and then ask

us to file your insurance at a later date.

You are ultimately responsible for payment of all

charges whether or not such charges are covered &

paid (either fully or partially) by your insurance.

IF YOU DO NOT HAVE HEALTH INSURANCE or IF YOU REQUEST A COSMETIC PROCEDURE:

Payment in full is due at the time of service.

We accept cash, check, VISA, MC, Discover AE.

We charge 18% APR on all balances over 90 days.

Our business office is available from 8AM to 4:30 PM Monday thru Thursday and from 8am to noon Friday to answer any questions or address any concerns you may have. If you receive a statement from our office, then we expect payment from you within 30 days. If you disagree with the balance for any reason please contact our business office immediately. We will no longer carry account balances over 90 days past insurance payment.

208-238-7546.

A parent who brings a minor child to our office for medical care is responsible for payment of all of the child’s charges. Unaccompanied minors will be denied non-emergency treatment unless pre-authorized by parent /guardian.

A $25.00 fee is charged for missed appointments. A $25 fee is charged for returned checks.

I hereby guarantee payment of all charges for medical treatment and services provided to me (or any dependent) by The Idaho Skin Institute. I understand & agree that if the office places my account with an agency or attorney for collection, the office shall be paid by me for all collection costs to the extent allowed by applicable law.

I HAVE READ AND AGREE TO THIS FINANCIAL POLICY:

____________________________DATE_____________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY

CREDIT/DEBIT/ACH POLICY

Print Patient Name: _________________________________

Date of Birth________________________

I understand it is the policy of The Idaho Skin Institute to

secure my credit or debit card information at the time of

my visit. The office acknowledges that we must comply

with the provisions of the U.S. law.

If, after a claim has been submitted to my insurance carrier:

1) the claim is denied for any reason: or 2) there is patient

liability (i.e. deductible, co-insurance, etc.); the office will send

a statement notifying me of the balance due. If this amount is

not paid within 30 days, then my credit or debit card will be

charged for the entire balance owed for treatment of services

provided to me or my dependent.

I understand my insurance company will also provide

notification of these charges with an explanation of benefits.

In the event this amount exceeds $250, the office will provide

a courtesy call to my primary number before charging my

credit card.

I understand that in the event my credit or debit card has

been charged for medical treatment or services and then my

insurance carrier subsequently makes payment to the office

for those charges, the office will issue a credit to my credit or

debit card.

Please circle one of the following:

Visa / MC/ Discover / American Express OR

Checking Account / Saving Account

Last 4 Digits of Card/Account number___________

Expiration Date: ____________________________

Name of Card Holder: _______________________

I hereby authorize The Idaho Skin Institute and its designated

employees to charge my credit/debit card or account as

designated above, the patient responsibility and/or denied

amount of medical treatment and services provided by the

office. The charge will be based on the medical treatment

rendered to me (or my dependent) and the usual and

customary charges made by the office for such treatment and

service. If payment is denied by my credit or debit card

company or banking institution, I will pay the entire amount

within 30 (thirty) days.

______________________________Date_______ Cardholder’s Signature