Patient Forms

Step 1 of 7 - Initial Questions

Patient Information

Patient Name*

First Last

Patient Gender*

Patient Date of Birth*

Patient Email

Patient Phone Number*

Your Address*

Street Address Address Line 2 City State ZIP Code

Patient Financial Responsibility Disclosure

Please read in full, thank you.

Dear Patient, Please be aware that your health insurance defines dermatology as a specialist. It is your responsibility to know what your insurance coverage benefits are. We highly recommend you call the number on the back of your insurance card and ask about your coverage for a specialist office on not only your office visit but also any in office procedures. Please know your deductibles/ co-insurance/ copay or any out of pocket costs that your insurance will not cover fully. This will protect you from any unknown bills you may receive from Lucid Dermatology. We strive to inform you about any possible charges that may incur if your insurance is not covering visits/procedures at 100%. Thank you for choosing Lucid Dermatology for your skin care needs. For any further questions regarding this matter please reach out to the Lucid Dermatology Billing Dept at (516) 887-7090 ext. 111 or 134

Financial Responsibility Signature*

By signing, I hereby attest that I have read and understood my financial responsibility.

Cancellation Policy for Appointments

Please read in full, thank you.

Any time you are unable to keep your appointment, we would appreciate a call in advance from you so that we may cancel your appointment and use the appointment time for another patient. This serves as notice that if you fail to give us a 24-hour notice of cancellation for a medical or aesthetician appointment, there will be a $25.00 cancellation fee. In addition, for cosmetic and surgical excision appointments there will be a $50.00 cancellation fee for failure to provide us with 24-hour notice. These fees are not covered by your insurance. You will bear complete financial responsibility for this fee. I understand Lucid Dermatology's appointment cancellation policy and understand my responsibility to plan appointments accordingly and notify the office appropriately if I have difficulty fulfilling my scheduled appointments.

Cancellation Policy Signature*

First Last

Please print your name.

Cancellation Policy Signature*

By signing, I hereby attest that I have read and understood Lucid Dermatology's Cancellation Policy.

Acknowledgment of Receipt of Notice of Privacy Practices

Please click on the link below and read in full, thank you.

HIPAA Policy Acknowledgement*

Yes, I have read in full the Notice of Privacy Practices

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly.
• Protected health information may be disclosed or used for treatment and payment.
• Obtain payment from third-party payers.
• Conduct normal health care operations such as quality assessments and physician certifications.

I have received, read and understand the Notice of Privacy Practices document containing a more complete description of the uses and disclosures of my health information. I understand that Lucid Dermatology has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time for a current copy of the Notice of Privacy Practices document. By signing this form, you consent to our use and disclosure of your protected healthcare information. Do we have your permission to:

Confirm appointments by leaving messages or speaking with family?*

Yes

Leave a message on your answering machine?*

Yes

Leave pre-medication reminders (if applicable)?*

Yes

Speak to household members concerning your care?*

Yes

Privacy Practices Signature (Patient Name)*

By signing, I hereby attest that I have read, understood, and selected Lucid Dermatology's Privacy Practices

Phone

This field is for validation purposes and should be left unchanged.

New Patients

Initial Questions

Primary Care Physician

Emergency Contact

Patient Information

Primary Insurance / Insurance Policy Holder

Secondary Insurance to File

Preferred Pharmacy

Medications

Allergies

Past Medical History

Patient Financial Responsibility Disclosure

Cancellation Policy for Appointments

Acknowledgment of Receipt of Notice of Privacy Practices

Testimonials

JAMAICA OFFICE

JAMAICA HOURS

ELMHURST OFFICE

ELMHURST HOURS

BRONX OFFICE

BRONX HOURS