New Patient Registration
Please complete every field. If the patient is under 18, fill in the parent or guardian section as well.
About you
Your doctor
For minors only
I hereby authorize payment, directly to Derm360 of benefits due to me from my insurance company, otherwise payable to me. I further authorize the release of any medical information required by my insurance carrier. I understand that I am financially responsible for charges, lab work and vaccines not covered by my insurance contract as performed in the office, and for any co-payment an/or deductible amount as specified in my insurance contract. I acknowledge that private health information material (HIPAA) is posted and available upon request.
New Patient Registration
Complete the primary plan. Complete the secondary plan only if you have one.
Coverage
Primary insurance
Secondary insurance
Where we send prescriptions
New Patient Registration
The more you can tell us here, the safer and faster your visit will be.
Patient
Today
Your family
Skin cancer — basal cell, squamous cell, melanoma:
Please Read and Initial
Initial each paragraph to confirm you have read it, then sign at the bottom.
Patient
Please initial each
Your deductible and copay for the office visit are collected on the day of your visit.
New Patient Registration
Please read
Your card
Your authorisation
I authorize Dermatology360, LLC d/b/a Derm360 to keep the card above on file and to charge it $75 for each appointment I miss, or cancel with less than 24 hours’ notice, under the policy above. I understand the charge is made automatically and that up to three attempts may be made. This authorization stays in place until I cancel it in writing. I will tell the office if the card is replaced, expires or is closed.
Office use only
Dermatology360, LLC d/b/a Derm360
Sign to confirm you were offered a copy of our Notice of Privacy Practices.
What you are acknowledging
I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of your Notice of Privacy Practices. I also understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.
Office use only
We have made the following attempt to obtain the patient’s signature acknowledging receipt of the Notice of Privacy Practices:
Dermatology360, LLC d/b/a Derm360
Please read both pages before signing. Signing lets us communicate with you by e-mail and records that you understand what that means.
Provider offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail has a number of risks that patients should consider before using e-mail communication. These include, but are not limited to, the following risks:
Do not use e-mail for anything urgent. If you need help quickly, call the office at 786-707-4888. In an emergency, call 911 or go to the nearest emergency room. E-mail is read during office hours only, Monday to Friday, 9:00am – 5:00pm.
Provider aims to answer non-urgent e-mail within 48 to 72 hours. E-mail sent on a Friday, a weekend or a holiday may not be read until the next business day. If you have not had a reply within 72 hours, call the office — do not assume the e-mail was received.
Provider will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, Provider cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Thus, the patient must consent to the use of e-mail for patient information. Consent to the use of e-mail includes agreement with the following conditions:
To communicate by e-mail, the patient shall:
The Provider shall have the right to immediately terminate the e-mail relationship with you if determined, in the sole Provider’s discretion, that you have violated the terms and conditions set forth above or otherwise breached this agreement, or have engaged in conduct which the Provider determines to be unacceptable.
Patient Acknowledgement and Agreement
I have discussed with the Provider or his/her representative and I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between the Provider and me, and consent to the conditions herein. I agree to the instructions outlined herein, as well as any other instructions that my Provider may impose to communicate with patients by e-mail. Any questions I may have had were answered.
Hold Harmless
I agree to indemnify and hold harmless the Provider and its trustees, officers, directors, employees, agents, information providers and suppliers, and website designers and maintainers from and against all losses, expenses, damages and costs, including reasonable attorney’s fees, relating to or arising from any information loss due to technical failure, my use of the internet to communicate with the Provider, and any breach by me of these restrictions and conditions.
Dermatology360, LLC d/b/a Derm360
This is optional. Your care does not depend on signing it.
What you are consenting to
I hereby give consent and permission to Dermatology360, LLC d/b/a Derm360 to record the appearance, physical likeness and/or voice on videotape, on film, or digital video disk, or other means, and/or take photographs of the appearance of (print name) ____________________ age (if minor) ____________.
Notwithstanding any prohibition as may be contained in Section 540.08, Florida Statutes, I hereby freely and voluntarily consent to the use and publication of my name, participation, picture, and/or likeness by Dermatology360, LLC d/b/a Derm360 and/or its employees and/or agents, as well as the entity seeking this consent, and photographs, video and/or audio for any and all purposes including, but not limited to, educational, promotional, advertising, and trade, through any medium or format, including, but not limited to, film, photograph, television, radio, digital, internet, or exhibition, at any time from this date forward until I revoke this consent in writing.
I acknowledge that Dermatology360, LLC d/b/a Derm360 is the sole owner of all rights in, and to, this visual and/or sound production and/or photograph(s) and the recordings thereof, and that it has the right to use or reproduce the resulting images and/or sound as often as it finds necessary. I acknowledge that the photographs, video and/or audio may be used indefinitely by television, radio, newspapers, magazines, newsletters, brochures, internet, intranet, or in other media once released.
Dermatology360, LLC d/b/a Derm360 has the right, among other things, to edit and/or otherwise alter the visual or sound recording, or photographs, as needed. I understand I will receive no compensation for the appearance of the above-named person or for participation in said productions. I agree to hold Dermatology360, LLC d/b/a Derm360, its employees and other parties harmless against claim, liability, loss, or damage caused by, or arising from, my participation in this production.
How to revoke this consent. You may revoke this consent at any time by letter to: Derm360, Attention Operations Manager, 7700 N. Kendall Drive, Suite 200, Miami, FL 33156. Revocation takes effect when we receive your letter. It does not apply to anything already published, printed or released before that date, which cannot be recalled.
I have read this Consent before signing and fully understand the contents, meaning, and impact of this consent. I understand that I am free to address any specific questions and have done so prior to signing this Consent.
For a patient under 18, the parent or legal custodian signs. If the patient is aged 12 or older, please have the patient sign as well. I have read this consent, or had it read to me, and I agree to my photograph, video or voice being used in the ways described above.
Dermatology360, LLC d/b/a Derm360
Tell us whether we may leave detailed messages about normal results, prescriptions and appointments.
Why we are asking
In an effort to relay normal results faster to our patients, we have implemented Electronic Medical Records.
I understand that in order for Dermatology360, LLC d/b/a Derm360 to leave detailed messages containing specific medical information on my voicemail or answering machine, I need to give my permission to Dermatology360, LLC d/b/a Derm360.
I further understand that in order for Dermatology360, LLC d/b/a Derm360 to text detailed messages containing specific medical information to my cell phone, I need to give my written express permission to Dermatology360, LLC d/b/a Derm360. I also understand that my healthcare information at Dermatology360, LLC d/b/a Derm360 is protected and a copy of the Notice of Privacy Practices is available upon my request.
Consent for messages
I give my written express consent to Dermatology360, LLC d/b/a Derm360 to leave detailed messages on my voicemail/answering machine about my NORMAL lab results, diagnostic and/or imaging results, prescription information, or appointment reminders.