HIPAA Certified Compliance

Patient Registration Form

Insurance Information

Please use your most current insurance ID card to complete the following fields. Please complete the Secondary Insurance area if you have a secondary or backup insurance policy.

Primary Insurance

Secondary Insurance

Survey

Medical History Form

Please complete all questions as accurately as possible.

Skin Cancer History

Please list any prior skin cancers. Your nurse or medical assistant will assist if needed.

Past Medical History

Select YES or NO if you currently have any of the following conditions.

Past Surgical History

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Skin History

Medications

List your medications. Please include all Rx, OTC, herbal, and vitamin supplements.

(If your medication list is more than our form allows, please bring your list to your visit)

Allergies

Social History

Review of Systems

Have you had any of the following in the past year?

Alerts

Please answer the following important questions.

Family Medical History

Please list major medical conditions of first-degree relatives.

Preventative Care History

Women Only

For Medicare Recipients Only

Medicare Account Information

Please Sign So We May Have Your Medicare Authorization On File

I authorize any holder of medical or other information about me to release to the Social Security Administration and health care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

clear signature area

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

Insurance Plan

If you have recently joined (or changed) to a Medicare HMO, please let our staff know so we can update your records and advise you if we are participating providers.

Supplemental Insurance or Medicare Advantage Plans

In the event of a major procedure or hospitalization, we request secondary insurance information for our records (supplemental Medicare insurance information). Please fill out below if you are covered by a plan which covers the 20% NOT covered by Medicare.

Policy Questions

HIPAA Privacy Form

Patient Record of Disclosures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.




The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to the uses or disclosures made pursuant to an authorization requested by an individual.

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.

clear signature area

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

Financial Policy and Assignment of Insurance Benefits

I hereby authorize and direct my insurance carrier to issue payment directly to Piedmont Plastic Surgery & Dermatology for medical services rendered to me and/or my dependents. I understand that I am responsible for any amount not covered by insurance. Payments and credits are applied to the oldest charges first, except for insurance payments, which are applied to the corresponding charges. I agree that if my insurance carrier sends payment to me for the medical services instead of to PPSD, I will immediately pay the amount due to PPSD. I agree it is my responsibility to understand my insurance benefits and to notify Piedmont Plastic Surgery & Dermatology immediately of any changes to my insurance coverage. I understand that it is my responsibility to obtain insurance authorization if it is required, and the payment is still my responsibility. Please remember that insurance is a contract between the patient and the insurance company, and ultimately you are responsible for payment in full to Piedmont Plastic Surgery & Dermatology.

I agree for Piedmont Plastic Surgery & Dermatology to service my account or to collect any amounts I owe. I may be contacted by telephone at any number associated with my account, including wireless telephone numbers, which could result in charges to me. I may also receive text messages or emails, using any email address I provide. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing device, as applicable. I authorize review, recording, and downloading of my prescription history records from the internet and/or other doctors’ data. I also authorize photography of my medical/surgical conditions and for my medical record ID. Patients whose accounts have been turned over to a collection agency will be responsible for the account balance and all costs associated with collection, including attorney fees. There will be a charge for form completion: disability, FMLA, supplemental insurance, etc. The forms require office staff time and time away from patient care for the physicians. We require 3 business days to complete the forms and requests. I authorize Piedmont Plastic Surgery & Dermatology to use and disclose the health and medical information for the purposes of treatment, payment, and health care operations. I understand I may review Piedmont Plastic Surgery & Dermatology’s “Notice of Privacy Practices” for additional information about the uses and disclosures of information described in this consent prior to signing this consent.

clear signature area

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

clear signature area

Draw your signature in the box, above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

Please review your entries before submitting.


(click submit only once, submission may take up to 60 seconds)