Olansky Dermatology Associates

Today: January 7th, 2009


	HOME: Quick Patient Check-In

Quick Patient Check-In

If you need to make an appointment now, click here.
You can view our cancellation policy here.

If you already have an appointment and you are a new patient or are an existing patient but have not seen us this year (2004), please complete the forms for a quick patient check in when you arrive.

Thank you for choosing our practice to serve your dermatology needs. Please review the following information that may answer questions you have about our services.

Dermatology procedures are mostly surgical in nature and may be applied to your yearly deductible.
On your specific insurance plan, many of our services may not be covered. Even with a managed care plan, there are many exceptions to the "copay rule." Should you have any questions, please consult your insurance company or human resources department. You may be told by your healthcare plan that they cannot "guarantee payment" on any service before the claim is filed. Once the claim is paid and we receive the "Explanation of Benefits," we will bill you accordingly.
We provide two kinds of services: 1) Medical necessary and 2) Cosmetic. We will bill your insurance for medically necessary charges. You will be responsible for cosmetic charges. We have a Waiver form that explains these separate procedures.
Insurance companies are aware of the different procedures patients request that are not considered "medically necessary." They term these procedures as "cosmetic" since without care to these items, your health would not be adversely harmed. Our doctors will tell you which services may be covered and those that definitely will not. We must ask that you leave this determination up to our doctor. We cannot file claims for cosmetic procedures and will require that you pay for them at the time os service.
Laboratory results are processed outside of our office including biopsies and bloodwork. The lab will bill your insurance first, then bill you for your portion.
We utilize the analysis of a dermatopathologist for determining biopsy results. Your insurance will be billed by the laboratory for this analysis. If there are any remaining charges unpaid, you will be billed by one of these laboratories: 1) Atlanta Dermatopathology or 2) Finan Dermatoppathology. Also this applies to the bloodwork processed by SmithKline Laboratories, who may also bill you for tests not paid by your insurance.

Please read the above carefully and initial below to indicate that you are aware of these special items. If you have any questions, our Business Office will gladly assist you.


Name:
Address:
Address (line 2)
Address (line 3)
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
E-Mail:
Social Security Number:
Sex:	M F
Birthdate:
Occupation:
Emergency Contact:
Emergency Contact Phone:
Person Responsible for Payment:
Relationship to Patient:
Name of Referring Physician:
Do you have insurance:	YES NO
Insurance Company Name:
Phone Number:
Policy Number:
Group Number:
Policyholder Name:
Policyholder DOB:
Insurance Claim Address:
May we email you your appointment confirmation and the latest updates in dermatological care?	YES NO
CONSENT TO TREAT: I consent to treatment rendered from the physician and his/her directed medical support staff at Olansky Dermatology Associates.
RELEASE OF MEDICAL RECORDS: I hereby authorize Olansky Dermatology Associates to release to me any medical reports or information that I request. I also authorize the release of my medical information to process my insurance claim(s).
FINANCIAL RESPONSIBILITY: I understand that I am responsible for payment for services rendered. This payment applies to any portion of the fees not covered by my insurance, including but not limited to: copayments, deductibles, co-insurance amounts, and any services, including cosmetic procesures, not covered by my insurance carrier(s). If uninsured, I am responsible for full payment. All patient payable fees are due at the time services are rendered. I also understand that Olansky Dermatology Associates does not participate with all insurance plans and its participation may change from time to time. If my insurance company denies payment, I will be held responsible for any outstanding balance owed to Olansky Dermatology Associates for services I have received.
Patient Waiver of Medical Necessity Form: The information below is needed so that we can better serve you when you arrive in our office. I will be responsible for payment. As a new patient, the initial office visit to evaluate your problem should be covered by your insurance company. You will only be responsible for the copay on your office visit at the time of service. For any procedure of treatment of these specific diagnoses, you will be responsible for the payment at the time os service, because these services may not be covered if they are considered not medically-necessary by your insurance company. We will file the insurance claim for you. Should the insurance company pay for these services, we will promptly refund to you any portion not considered "patient liability." Seborrheic keratoses (raised crusty brown "moles") Dermatosis papulosa nigra (multiple small seborrheic keratoses of the face) Benign growths (such as "moles") Sebaceous hyperplasia ("overactive" oil glands of the face) Telangiectasias of the face (small "broken" blood vessels of the face) Lentigo Keloids Skin tags Milia ("whiteheads") Cherry angiomas (red "moles") Cysts I will be responsible for payment. These services WILL NOT be covered by your insurance company because they are not considered medically-necessary. You are fully responsible for payment of these procedures/services at the time of service. No claim will be filed to your insurance company for these services. Should you file an insurance claim from this visit, we will not take any writeoff or discount for services rendered. Chemical Peels Wrinkle treatment with Retin-A and/or glycolic acid Removal or treatment of benign asymptomatic growths (noted above) Sclerotherapy for spider varicose veins Collagen, fat or silicon injections Dermabrasion Facial lifts Liposuction Scar revisions Blepharoplasty Tattoo removal Hair loss Ear piercing

Describe the reason for your visit:
When did this problem start (approx.):
Has it ever happened in the past?
Please list any medicine(s) you take regularly, including non-prescription, hormone pills, and aspirin:
Please list any vitamins you take regularly:
Do you have a personal or family history of skin cancer?
Have you a personal or family history of malignant melanoma?
Have you had changing or suspicious looking moles: (black, bleeding, itching)?
Have you a personal or family history of large scars or keloids?
Have you ever received treatment for a tumor or growth?
Do you have sinus trouble, asthma, hay fever, or other allergies?
Please indicate if you are allergic or have had a reaction to any of the following (Hold down CONTROL to pick multiple items in list to right):	Please list other reactions here
Do you smoke or drink Alcohol?
Have you ever tested positive on an HIV test?
Have you ever had hepatitis, jaundice, or liver disease?
WOMEN ONLY
Are you pregnant?
Are you taking birth control pills?
Are you Nursing?
Do you have any problems associated with your menstrual period?