500 Superior Ave #335, Newport Beach, 92663, CA BILLING PATHOLOGY
To Make an Appointment Text or Call: 949.706.1469
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New Patient Paperwork

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    Name (Last, First, MI):
    Date of Birth:
    Sex:

    Address:

    City:

    State:

    Zip Code:

    Home Phone:

    Cell Phone:

    Email:

    Last 4 numbers of Social Security #:

    Occupation:

    Employer Name:

    Work Address:


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    Spouse:



    Occupation:

    Employer Name:


    Primary Care Physician:

    Telephone:

    Primary Care Physician Address/City:


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    Who Referred you to our Office? Check or explain:

    Insurance Information -- Guarantor Information --












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    Patient Basics: Meaningful Use
    Preferred Language:

    Race:

    Ethnicity:

    Confirm your Pharmacy name and City:
    Pharmacy address & phone number:

    Emergency Contact
    Name:
    Relationship to Patient:
    Phone Number:

    Treatment Consent
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    Financial and Billing Policies

    Thank you for choosing Pure Dermatology & Cosmetic Center. We are committed to providing excellent skin health care in a patient focused environment. We are contracted with several insurance plans and will directly bill your insurance under these plans.


    We understand that billing and payment for health care services can be confusing and complicated. It is important for you to know the information contained in your specific health plan, including any co-payments, deductibles, and other provisions. If you have any questions, we encourage you to call your health plan’s member services department. Their number should be listed on the back of your insurance card.


    We will submit claims to your insurance company. Because of this, we make a copy of your insurance card at every visit. We also ask that you inform us if your person or insurance information changes. The lack of current information may cause delays in care and make you personally responsible for the cost of the entire visit. If your office visit precedes the effective date of your insurance coverage or is not covered by your insurance, you will be held responsible for all fees incurred as a result of your visit.

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    Co-payments, Deductibles, and Co-Insurance


    Co-payments are due at the time of your office visit. Under the terms of our contract with various insurance plans, we cannot waive any co-payments, deductibles, or co-insurance amounts defined as patient responsibility. If you have any questions regarding your copayments or deductibles, please call your insurance company. For your convenience, we accept cash, checks, all major credit cards, and Care Credit.


    Payment is required for all services at the time they are rendered. If you are in an insurance plan that we participate in, in general, only applicable copayments and deductibles will be collected at the time of the service and we bill insurance for you as a courtesy. However, we do reserve the right to collect full payment from the patient for any procedures performed. The patient is responsible for any/all charges not paid by any insurance company including third party laboratories or pathologists. I agree to make in full prompt payment to Pure Dermatology when billed for any/all charges not covered. Further, I authorize payment directly to the provider for medical insurance benefits payable to me under the terms of my policy. We do reserve the right to change our financial policy at any time.

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    Assignment of Payment


    I hereby authorize payment directly to Pure Dermatology of any medical or surgical benefits payable to me under the conditions of my policy for services rendered.

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    Outside Services


    To provide the best care possible, Pure Dermatology & Cosmetic Center may send specimens to an outside source for processing. Examples of these services are pathology and laboratory testing. If we send specimens to an outside office, you will receive a separate billing statement from the outside pathologist or laboratory. These charges will be in addition to those services rendered by Pure Dermatology.

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    Cosmetic Procedures


    Elective cosmetic procedures are not covered by insurance companies. You are financially responsible for all charges associated with elective, cosmetic and non-covered procedures. If you are scheduled for any cosmetic procedure, please note, we require at least 48 hours notice to either cancel or reschedule your procedure so that we may accommodate another patient in your appointment slot. A notice less than 48 hours will result in a $100.00 late cancellation fee.




    All Cosmetic Consultations require a $150.00 deposit in order to book the appointment. The $150 deposit can be applied towards any treatment or product sold in the office, or your next appointment deposit. If you decide to not do any treatments or purchase anything in our office, the $150 fee is considered a consult/visit fee for your appointment.




    All patient payments for Cosmetic related services, or products are NON-REFUNDABLE. If patient wishes to cancel treatment credit will be applied




    A 50% deposit is due at the time of booking a treatment date to secure your appointment and the time of your provider. All treatments must be paid in full at the time of the 1st appointment.*
    *If any promotions are given to you, treatments are paid in full at the time of booking.




    By signing below, you agree to the current office policies and regulations of Pure Dermatology Cosmetic & Hair Center.

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    Late Charges and Other Fees


    Accounts with balances over 90 days old are subject to late fees

    Accounts referred to a collection agency may be subject to a $100.00 collection fee, attorney fees, and/or the percentage allowed under California state law.

    There is a $25.00 fee for all checks returned for NSF (non-sufficient funds).

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    Office Visits/PDT


    If you are unable to keep your general dermatology, follow-up, or cosmetic appointment , we ask that you notify our office by phone at least 24 hours in advance. We often have patients who can be scheduled in your appointment slot if you notify us of the cancellation with sufficient time. If your cancellation is within 24 hours of your appointment, you may be charged a $100.00 missed appointment/late cancellation fee. If you continue to miss appointments, you may be dismissed from this practice.

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    Surgical Procedures


    If you are scheduled for any surgical procedure, please note, we require at least 72 hours notice to either cancel or reschedule your procedure so that we may accommodate another patient in your appointment slot. A notice less than 72 hours will result in a $250.00 late cancellation fee.

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    Past Medical History (Please check all that apply)

    Past Surgical History (Please check all that apply)

    Skin Disease History (Please check all that apply)



    Do you wear sunscreen?
    If yes, what SPF?:
    Do you tan in a tanning salon?
    Do you have a family history of Melanoma?
    If yes, which relative(s)?:

    50%

    Medications (Please list all current medications)
    Allergies (Please list all allergies)

    Current Skincare Regimen
    Morning:
    Evening:

    Social History (Please check all that apply)
    Do you tan in a tanning salon?

    Are you a Smoker?
    If you’re a smoker, would you like help quitting?

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    How severe is your problem?
    How severe is your problem?
    Years
    Months
    Weeks
    Days
    Is your problem (please check one of the following):
    Pertinent History: Please check all that apply:
    Additional History:

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    Review of Systems: Are you currently experiencing any of the following?

    Alerts (Please check all that apply)

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    Digital Photo Consent
    Federal law guarantees a patient’s right to maintain the privacy of medical information. Photographs taken before, during, and after medical procedures may be considered part of the medical information. Please note that the release of all photographs, videos, illustrations, or otherwise is addressed at the time of taking your photographs for medical records kept with Pure Dermatology & Cosmetic Center.
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    Notice of Privacy Practices
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    Pure Dermatology employees may leave me a voicemail with Protected Health Information to the following number:

    Please identify any individual(s) with whom Pure Dermatology employees may discuss your medical condition and/or financial information (optional):

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    To our patients, this notice describes who health information about you (as a patient of Pure Dermatology) may be used, disclosed, and how you can obtain access to your health information. This is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1966 (HIPAA).


    Pure Dermatology is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following information:


    The following circumstances may require us to use or disclose your health information:


    1. To public health authorities & health oversight agencies that are authorized by law to collect info.

    2. Lawsuits and similar proceedings in response to a court of administrative order.

    3. If required to do so by a law enforcement official.

    4. When necessary to reduce or prevent a serious threat to the health & safety of another individual or the public. These disclosures would only be made with persons or organizations who are able to help prevent such a threat.

    5. If you are a member of U.S. or foreign military (including veterans) and if required by the appropriate authorities.

    6. To federal officials for intelligence and national security activities authorized by law.

    7. To correctional institutions or law enforcement if you are an inmate or under the custody of a law enforcement official.

    8. For Workers Compensation and similar programs.


    Your rights regarding your health information:


    1. Communications: You can request that Pure Dermatology communicate with you about your health & related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work. We will accommodate all reasonable requests.

    2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or healthcare operations. Additionally, you have the right to request that we restrict disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required by law to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

    3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient & medical/billing records, but not including psychotherapy notes. You must submit your request in writing to Pure Dermatology or contact the office for further information.

    4. You may ask us to amend your health information if you believe it is incorrect or incomplete, as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing & submitted to Pure Dermatology, or contact the office for further information. You must provide us with a reason that supports your request for amendment.

    5. Right to copy of this notice: You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy at any time. To obtain a copy of this notice, contact our office.

    6. Right to file a complaint: If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the office for further information.

    7. Right to provide an authorization for other uses and disclosures: Pure Dermatology will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If you have any questions regarding this notice or our health information privacy policies, please contact Pure Dermatology.


    HOAG HEALTH INFORMATION EXCHANGE (HIE)


    We participate with HIE. HIE is an electronic system through which it and other participating healthcare providers can share patient information according to nationally recognized standards and in compliance with federal and state law that protects your privacy. If you choose to opt out of the HIE, we will continue to use your medical information in accordance with this Notice of Privacy Practices and the law, but will not make it available to the HIE. To opt out of the HIE, please contact the Hoag Director of HIE by phone at 949-764-8722.


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    Cosmetic Questionnaire We’d love to hear your cosmetic interests; Please select all that apply

    Consent for Photography / Authorization for Use and Disclosure


    This form is to be used only for photographs taken for treatment for Pure Dermatology & Cosmetic Center’s own healthcare operations, as allowed under the Federal Privacy Laws. The term “photograph” as used herein includes video or still photography, digital, any other format, and any other means of recording or reproducing images.

    I hereby authorize the use or disclosure of photography or other purposes including research publication, outside education, marketing, and public relations (i.e. Pure Dermatology & Cosmetic Center publications, websites, printed materials, social media websites, etc.) If the photograph will be used for office marketing purposes, all measures will be taken to make the images non-identifiable. Pure Dermatology & Cosmetic Center will not share such photographs or images for any other purpose without my specific written consent. I and my successors or assigns hereby hold Pure Dermatology & Cosmetic Center, its employees or physician(s), and any other person(s) participating in my care harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.

    I have read and understand the terms of this document. I have had an opportunity to ask questions about the use or disclosure of my health information and about the contents of this form. I acknowledge and agree to the terms and conditions of this document.






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