Chesterfield Valley Dermatology Helen Kim-James, MD …static.squarespace.com/static/51f91565e4b0f0372667e999/t... · Chesterfield Valley Dermatology Helen Kim-James, MD 100 Chesterfield

Chesterfield Valley DermatologyHelen Kim-James, MD100 Chesterfield Business Parkway, Suite 110Chesterfield, Mo 63005P: 636.532.0990 f: 636.532.0993

PERSONAL INFORMATION

NAME: Last:

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CHESTERFIELD VALLEYDERMATOLOGY

PATIENT INFORMATION FORM

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Age: SSN: Sex: M / F

Mailing Address (city, state, zip):

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Marital Status: M / S / D / W

Pharmacy (Location & Phone Number):

EMERGENCY CONTAC

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Name:

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REFERRAL INFORMATION

How Did You Hear About Us? MD/lnsurance/ Friend/ Publication/ Other

Referring Doctor: Primary Care Doctor:

RESPONSIBLE PARTY (if different from patient)

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INSURANCE COVERAGE - PRIMAR

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SSN: Relationship: Self/ Spouse/ Child/ Other

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INSURANCE COVERAGE - SECONDAR

Company:

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Subscriber (insured):

SSN: Relationship: Self/ Spouse/ Child/ Other

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Chesterfield Valley Dermatology Medical History

Patient Name: Age: Date:How were you referred to our office?Are you allergic to any medications? If yes, what?Please list the medications you are taking (prescription and over-the-counter):

Have you ever had a reaction to anesthesia (numbing medication)?

Do ever had:ArthritisArtificial Joint or ValveAsthmaAutoimmune Disease (Lupus, MS,other)Blood ClotsCancer (Other than Skin Cancer)Chest PainChronic CoughDiabetesEpilepsy/SeizuresFaintingFever Blisters/Cold SoresHeart AttackHeart Murmur

Y NY NY NY N

Y NY NY NY NY NY NY NY NY NY N

Hepatitis B or CHigh Blood PressureHIV/AIDS ExposureIrregular Heart Beats

Kidney ProblemsMitral Valve ProlapseNausea or Diarrhea on AntibioticsPacemakerRequire Antibiotics for DentistShortness of BreathSinusitisThyroid ProblemsTuberculosisYeast Infection from Antibiotics

Y N

Y NY NY N

Y NY NY NY NY NY NY NY NY NY N

List any other diseases or conditions:

List any surgeries:

Do you know, or have you ever had:Skin Cancer (melanoma, basal cellcarcinoma, or squamous cellcarcinoma)"Pre" cancerFamily History of MelanomaProblems healing

Y N

Y NY NY N

Specific skin disease (eczema,psoriasis, rosacea, or other)

Large scars or keloidsDifficulty in slopping bleedingSkin rashes to foods

Y N

Y NY NY N

Do you drink alcohol? If yes, how many drinks per day?Current or history of IV/i l l ic i t drug use? Y NDo you smoke? If so, how much?(Women) Are you pregnant? Y N Are you planning pregnancy soon? Y N

What is your occupation?

CVD POLICY INFORMATION

Insurance/Payment: Current insurance card(s) and copayment are expected at time of service. If you do not haveyour insurance card(s) at time of visit you will be considered a self pay patient. If your insurance requires areferral, it is your responsibility to acquire the referral before appointment date. If referral is not received beforeappointment date and you still want to be seen that day you will be considered a self pay patient. You areresponsible for any charges incurred if you provide incorrect information or if you do not update any insurancechanges at each visit. Each patient's visit is accurately coded and documented to the best of our ability.Preventive care visits do not apply to dermatologic services and are not used by our office. Once the insurancecompany has paid its portion of the office charges, please be aware that you will receive a statement for anycharges that you are responsible for (ie: copayment, coinsurance, deductible). Please understand that payment forthese charges are due at the time the statement is received and that you will be charged a $10 late fee everymonth for any charges that are not paid before the next billing statement. Patients that have received twostatements in the mail must pay balance prior to further services. Chesterfield Valley Dermatology does not offerpayment plans (as of 2014). There will be a $30 service fee on all returned checks.

Cancellation/Late Arrival: We value your time and make every effort to stay on schedule. If you are running lateto your appointment, please call the office to notify us so we can accommodate or reschedule the appointment inconsideration for other patient's appointment times. Please allow 24 hour prior notice should you need to cancelor reschedule an appointment. Failure to notify the office and not appearing for your office visit will result in a NoShow charge of $30 and we reserve the right to charge $75 for a missed surgery/procedure.

Minors: For your child's safety, a parent must accompany children for their initial visit. For additional visits awritten consent to be seen without a parent is permitted. In Case of Divorce: The parent who brings the child isstating they have "joint legal custody" or "sole legal custody" and can make health care decisions for the child. Theparent who brings the child is considered the Guarantor. They have accepted responsibility for the child and theircharges. The statements will be sent to the Guarantor. It is expected that in the case of divorce the two partieswill handle payment arrangements without the involvement of the office.

Billing for Delinquent Accounts: If your account becomes delinquent (not paid after second billing statement), itwill be referred to a collection agency. Accounts placed in collection will be assessed a 40% collections fee by theagency in addition to any attorney fees or court costs that may incurred in an attempt to collect the debt.

I, (please print name/relationship) / / SELF, am the responsibleparty for (patient) and take full responsibility of any services not covered by theinsurance company for any office visit with Dr. Helen Kim-James. I (initial) have filled all the information tothe best of my knowledge and agree with the above policies for Chesterfield Valley Dermatology (CVD).

Patient or Responsible Party Signature: X DATE:

RECEIPT OF NOTICE OF PRIVACY PRACTICES: My signature below indicates that I have received and/or reviewed acopy of my physician's Notice of Uses and Disclosures of Protected Medical Information (Notice of PrivacyPractices).

Patient or Responsible Party Signature: X DATE:

[Copies of Notice of Privacy Policies are available upon request]

Chesterfield Valley DermatologyHelen Kim-James, MD

EVALUATION OF SKIN LESION(S)

It is important that you read this information carefully and completely.

INTRODUCTIONSkin cancer detection, treatment, and prevention are team efforts that involve the combined efforts of youand your doctors. The best way to prevent skin cancer is to wear appropriate skin cover and sunscreen,particularly in the summer months. Indoor tanning facilities should be avoided.

If there is a lesion or growth that you or one of your other doctors has a concern about, please point it outto Dr Kim-James. In addition, if you have a mole which has grown or changed in color, it should bepointed out as well. Any growth on the skin that itches or has been bleeding should be examined.

Your dermatologist may give you an opinion about a skin lesion but without a biopsy it is only anestimate. It is important to note that no physician can ever be absolutely sure that any skin lesion is non-cancerous without removing it. Although uncommon, even a skin biopsy can be inaccurate at times.

Skin cancer screening is a tool that a dermatologist may recommend to help detect skin cancer on yourbody. Lesions that are unusual or appear to be cancerous will be pointed out, and may be biopsied.Whenever a lesion is biopsied, it is sent to a pathologist to be examined. Lesions which appear to bebenign (non-cancerous) will not all be pointed out to you by your dermatologist.

The frequency of your recommended skin cancer screenings is determined by your personal and familyhistory. In order to have a skin cancer screening, it is important that you disrobe and wear a gown. Skincancer screening appointments must be made in advance so that the proper amount of time is available.

WHAT !S A BIOPSY?When a lesion is biopsied, it is only sampled so that a diagnosis can be made. This means that if thegrowth is diagnosed as a skin cancer, more work will need to be done to ensure that it has been properlytreated. This may involve a second surgery either by your dermatologist, a Mohs surgeon (a subspecialtyof dermatology), or a plastic surgeon. The decision is based on what type of cancer you have and where itis located on your body. In some cases, the cancer may also be treated with a chemotherapy cream orradiation.

WHAT IS LIQUID NITROGEN?Liquid nitrogen is a very cold liquid which dermatologists use to treat pre-cancerous lesions. Thenitrogen will destroy the pre-cancerous cells and prevent them from turning into a skin cancer. When thistechnique is used, the treated area is expected to blister, then scab, then heal. The healing processgenerally takes a week, but can take as long as 2-3 weeks. If a lesion is treated with liquid nitrogen and itdoes not fully heal, or if it comes back, it is important that you let your doctor know.

HEALTH INSURANCEMost health insurance plans cover both skin cancer screening and treatment.

DISCLAIMERInformed-consent documents are used to communicate information. This informed consent processattempts to define principles of risk disclosure that should generally meet the needs of most patients inmost circumstances.

However, informed consent documents should not be considered all inclusive in defining other methods

Initials 1 Rev. 9/2012

of care and risks encountered. Your physician may provide you with additional or different informationwhich is based on all the facts in your particular case and the state of medical knowledge.

Informed-consent documents are not intended to define or serve as the standard of medical care.Standards of medical care are determined on the basis of all of the facts involved in an individual case andare subject to change as scientific knowledge and technology advance and as practice patterns evolve.

It is important that you read the above information carefully and have all of your questionsanswered before signing the consent below.

CONSENT FOR EVALUATION OF A SKIN LESION

1. I hereby authorize Helen Kim-James, MD to evaluate my skin lesion(s).

2. I have received the following information sheet: EVALUATION OF SKIN LESION(S)

3. 1 understand that if I do not disrobe, a complete skin cancer screening cannot be performed if Iam scheduled for one.

Patient or Person Authorized To Sign for Patient.

Date

Initials 2 Rev. 9/2012