History and Intake Form
Past Medical History:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other (Including any other type of cancer or any other problems you see a doctor for or take medicine for)
Past Surgical History:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Skin Disease History:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do you wear Sunscreen?
 
 
 
Do you tan in a tanning salon?
 
 
 
Do you have a family history of Melanoma?
 
 
Social History:
 
Cigarette Smoking:




 
Alcohol Use Per Day



 
 
How often do you exercise?




 
What is your caffeine use?




 
Patient Data:
 
Race:






 
Ethnicity:


 
Preferred Language


Pharmacy:
Consent for Release of Protected Health Information
 
I,
 
 
consent to the release of protected health information that is required to carry out treatment, payment of healthcare operations on my behalf.

I have read the Notice of Privacy Practices and am aware of the following:

  • I have the right to place restrictions on the way my protected health information is used or disclosed.
  • I have the right to revoke my consent for the use and disclosure of my protected health information at any time. I understand that, if I choose to revoke my consent, I must submit a written statement that is signed by me.
  • I understand that Beatrice Keller Clinic must immediately comply with my request to revoke consent, except to the extent that it has already taken some action that was based on my original consent.
  • Beatrice Keller Clinic has reserved the right to change from time to time its privacy practices that are described in the Notice of Privacy Practices. Whenever we change our practices, we will modify the Notice accordingly; and we will inform you by placing the amendment date at the bottom of the posted Notice.
I understand that occasionally Beatrice Keller Clinic may need to contact me concerning health matters. On these occasions I give my permission to:
 
Leave a message on my home phone
 
 
 
Speak to another authorized party
 
 
 
 
 
 
 
 
Financial Policy Of Beatrice Keller Clinic
Please read this notice so you can make an informed decision about your care.
  1. Payment is due at the time of service if you have no insurance and/or no insurance referral.
  2. If you are unable to pay at the time of service, you need to make arrangements with the billing department prior to your visit. Their number is 623-972-3992 ext. 313
  3. Co-insurance and/or co-payment, along with any deductibles, are due at the time of service.
  4. Please present a current I.D. card when making payments with a check. The clinic will not accept "starter" checks. The check must have your printed name and address on it. Checks returned by your bank due to insufficient funds will cause your account to be assessed a $25.00 fee.
  5. Please present your current insurance card at every visit.
  6. Minors under 16 must be accompanied by an adult or a guardian. Minors over 16 must have current notarized "consent to treat" on-hand at time of service. The custodial parent is responsible for any balance due on services rendered once insurance has paid.
  7. To complete disability and/or cancer insurance form(s) (other than your standard health insurance forms) we will charge a fee of $25 per form.
  8. A no show fee of $25-$75 will be assessed for appointments not cancelled 24 hours in advance.
  9. You will be billed for any pathology or blood test not performed in our office. The bill will come from the outside lab facility providing the service. Some or all tests ordered by your physician may not be covered by your insurance and may be an out-of-pocket expense to you.
  10. There could be two charges for pathology. One from Beatrice Keller Clinic and one from the outside lab.

Thank You.

I understand the Beatrice Keller Clinic Financial policy.
 
 
 
 
Patient Information
 
 
Name
 
 
 
 
Mailing Address
 
 
 
 
 
 
 
 
 
 
 
 
 
Parent or Responsible Party (if different from patient)
Name
 
 
 
 
Address
 
 
 
 
 
 
 
 
 
 
 
 
Insurance Information (Please present insurance card at time of check in.)
 
Primary
 
Secondary
 
 
 
 
 
 
 
I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician.
 
 
 
In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. For those patients, applicable copayments and deductibles will be collected. We accept payment in the form of cash, check, or credit card. In the event of hospitalization or major procedures, our office may file with the appropriate insurance.
Your signature below signifies your understanding and willingness to comply with this policy.
 
 
 
 
Copy of insurance card (both sides) attached.