Patient Registration Form | Skin Cancer Treatment Aventura, FL

Patient Information

First Name *

Middle Initial

Last Name *

Date of Birth *
[mmddyyyy]

Address *

City *

State *

Zip Code *

Cell Number*
(with area code)

Work Phone *
(with area code)

Home Phone *
(with area code)

Email Address *

Gender *

Marital Status *

Spouse's Name

In an EMERGENCY, who should be notified?

Name		Relationship		Phone

Insurance Information
If you have insurance, Please call the office to verify your coverage.

Please continue to the next step, you can come back to this page if needed.

Dermatology Medical History

Name:
DOB:

Please select all those that apply

Yes No

Do you smoke? *

Yes No

Do you vape? *

Yes No

Do you go to a tanning salon? *

Yes No

Are you allergic to dental anesthesia? (Novocain, Lidocaine, Xylocaine ) *

Yes No

Have you ever had skin cancer? *

Yes No

Has anyone in your family had skin cancer? *

Yes No

Do you have problems with healing? *

Yes No

Do you develop keloids (scars) after surgery? *

Yes No

Do you take blood Thinners or aspirin? *

Please select all those that apply

Yes No

Skin rashes to medications *

Yes No

Skin rashes to foods *

Yes No

Skin rashes to environment *

Yes No

Diabetes *

Yes No

Thyroid problems *

Yes No

Pacemaker or Defibrillator *

Yes No

Kidney problems *

Yes No

Artificial joint *

Yes No

Stomach problems *

Yes No

High Blood Pressure *

Yes No

Epilepsy *

Yes No

History of Internal Cancer *

Yes No

Migraines *

Yes No

Asthma *

Yes No

Leg vein inflammation *

Any surgical procedures in the last 6 months? *	Yes No

Do you have allergies to any medicines? *	Yes No

Medicines, prescribed or over-the-counter

Get the Latest Information

Name:
DOB:

We periodically send e-mail or text messages with the latest information from Resnik Skin Institute, from new product information and product promotions to the latest in cutting edge skin care. We will never give or sell your information to anyone or any business. Completing this form gives us permission to add you to our list. You can “unsubscribe” at any time with a single click on the link at the bottom of every email message we send.

Email *

E-Prescription Service

We are now submitting prescriptions electronically, to make your life easier and to be in compliance with federal mandates. Please give us the name, telephone and zip code of the pharmacy you would like to have as your primary pharmacy.

Pharmacy Name

Telephone

Zipcode

POLICY ON INSURANCE AND ASSIGNMENT OF BENEFITS

Name:
DOB:

As physicians, our relationship is with you, not your insurance company. Please understand that:

Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. We have a separate contract with your insurance company.
Our fees fall within the acceptable range of most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 50%, or 80%) of “usual, customary, and reasonable fees” for this region. This statement does not apply to companies who reimburse based on an arbitrary "schedule of fees” that bears no relationship to the current standard and cost of care in this area.
Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover, and do not readily disclose this fact until after the service has been rendered.
Only one procedure is done per visit. If necessary, a follow-up visit may be scheduled to discuss results.

For our HMO patients: Your insurance may require you to have a referral for every visit to Dr. Resnik. It is your responsibility to obtain your referral prior to your visit with Dr. Resnik. If you do not have your referral, your visit will be deferred until one is obtained, delaying your treatment and care.

I hereby instruct and direct my Insurance Company, to pay by electronic deposit of funds or check made out to Resnik Dermatology Aventura, P.A.

If my current policy prohibits direct payment to doctor, I hereby also instruct and direct you to make out the check to me and mail it to the address above, for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above‑mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.

A photocopy of this assignment shall be considered as effective and valid as the original.
I authorize Resnik Dermatology Aventura, P.A. to deposit checks received on my account.
I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Name of Patient/Policyholder*
05-13-2021
Date

* By completing this form digitally and typing my name here, I acknowledge that this is my digital signature and understand it to be as legally binding as my cursive signature.

FINANCIAL POLICY

Name:
DOB:

We are committed to providing you with the best possible care. In order to achieve these goals, we need to ensure your understanding of our payment policy.

Payment for cosmetic and private pay services is due at the time those services are rendered. We accept cash, checks (for established patients only), American Express, MasterCard, Visa and Discover.

All co-pays, deductibles and coinsurance amounts as verified with your insurance plan are due at the time of service and cannot be waived. All patient balances determined to be your responsibility by your insurance company will be automatically charged to the credit card provided by you in our EASY PAY program.

I understand if I have an unpaid balance to Resnik Skin Institute and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. All balances over 60 days are automatically referred to a collection agency. A $35 collection fee and all legally applicable interest will be added to the total owed. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts.

In order for Resnik Skin Institute or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Resnik Skin Institute and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.

Claims for insurance companies with which we participate are submitted electronically by our billing company. We do not participate with Medicaid as primary or secondary coverage. Please notify the secretary before your appointment if you are a Medicaid patient.

If your check is returned unpaid, a charge of $35 for insufficient funds will be added to your account balance.

Missed appointments and appointments cancelled without 24 hours advance notice will incur a $50.00 charge.

Name of Patient/Policyholder (If patient is minor)*
05-13-2021
Date

* By completing this form digitally and typing my name here, I acknowledge that this is my digital signature and understand it to be as legally binding as my cursive signature.

CONSENT TO RECEIVE COMMUNICATIONS
VIA KLARA OR EMAIL
HIPAA-COMPLIANT SECURE COMMUNICATIONS SYSTEM

Name:
DOB:

I agree to send and receive information securely via Klara
My cell number to enroll in Klara is:

You will receive a text invitation to join Klara that will give you further instructions. I can opt out of Klara through my account.

I agree to receive occasional communications via Email:
My email is:

I agree to Resnik Skin Institute’s notice of privacy policies, located at https://www.drresnik.com/privacy-cosmetic-dermatologist-miami-florida.php

I can opt of email communication by clicking the Unsubscribe link included in every email.

Patient name*
05-13-2021
Date

* By completing this form digitally and typing my name here, I acknowledge that this is my digital signature and understand it to be as legally binding as my cursive signature.

Notice of HIPAA Acceptance	Name: DOB:
You acknowledge by your signature below that you have read and agreed to our policy on Access to your Protected Health Information. Simply stated, you must provide us with a signed Records Release before any part of your medical record can be given to anyone. If you wish Dr Resnik to discuss your medical record with anyone, you must either list them here or sign a Release of Information to Third Party. The protection of your medical record is our greatest responsibility.
Name	Relationship to Patient








* I certify as my signature the information submitted is accurate.

My mobile phone number is: *
Patient signature Date *	05-13-2021

Psoriasis Prior Therapy History		Name: DOB:

Please select all those that apply		Check all that apply

UVB Light Therapy

PUVA Light Therapy Systemic

PUVA Light Therapy Topical

Cyclosporine by mouth

Methotrexate by mouth or injection

Retinoids by mouth (Tegison, Soriatane, acitretin)

Imuran (Azathioprine)

Remicade (Infliximab)

Humira (Adalimumab)

Simponi (Golimumab)

Stelara (Ustikinumab)

Taltz (Ixekizumab)

Otezla (Apremilast)

Cortisone (steroids) by mouth

Cortisone (steroids) injected into arm or buttock

Cortisone (steroids) injected into psoriasis plaques

Cortisone (steroids) rubbed into skin

Retinoids (Differin, Tazorac, Retin-A) rubbed into skin

Calcipotriene (Dovonex, Taclonex, Vectical) rubbed into skin

Pulse Dye Laser

XTRAC Laser

Please continue to the next step, you can come back to this page if needed.

Hidradenitis Suppurativa Prior Therapy History	Name: DOB:

Please select all those that apply	Check all that apply

Loose cotton clothing

Domeboro (aluminum acetate), Burows solution

Clinical strength anti-perspirants

Zinc gluconate tablets by mouth

Clindamycin solution rubbed on skin

Dapsone cream rubbed on skin

Steroids by mouth

Cortisone injected into muscle

Cortisone injected into affected skin

Methotrexate by mouth or injection

Accutane (isotretinoin) by mouth

Soriatane (acitretin) by mouth

Spironolactone by mouth

Finasteride by mouth

Dutasteride by mouth

Robinul (glycopyrrolate) by mouth

Cyclosporine by mouth

Azathioprine (Imuran) by mouth

Infliximab (Remicade) by intravenous

Adalimumab (Humira) by injection

Golimumab (Simponi) by injection

Ustekinumab (Stelara) by injection

Anakinra (Kineret) by injection

Hair removal laser

Lancing of boils (incision and drainage)

Wide surgical excision

HS unroofing

HS CO2 laser surgery

Please continue to the next step, you can come back to this page if needed.

Vitiligo Prior Therapy History		Name: DOB:
Please select all those that apply		Check all that apply

Cortisone (steroids) rubbed on skin

Protopic rubbed on skin

Elidel rubbed on skin

Pseudocatalase cream

Cortisone (steroids) by mouth

Cortisone (steroids) injected into Vitiligo patches

Vitamin therapy

Aspirin Therapy

Narrowband UV light in stand-up box

Narrowband UV light with handheld wand

PUVA (UVA light with Psoralen by mouth)

UV laser

Vitiligo Minigraft surgery
Please continue to the next step, you can come back to this page if needed.


Please remember to bring your insurance card and a picture ID If you have any questions regarding this form or questions, please call (305) 692-8998 and speak with one of our registration specialists.