Patient questionnaire and history

HELLER DERMATOLOGY CENTER
JEFFREY J. HELLER, D.O., F.A.A.D.
511 N. CLYDE MORRIS BLVD.
DAYTONA BEACH, FL 32114
790 DUNLAWTON AVE., SUITE D
ADULT PORT ORANGE, FL 32127
(TO HANDOUT, FAX,
PHONE (386) 239-8700
MAIL, OR E-MAIL) FAX (386) 239-7070
PAGE 1 OF 8

DEAR PATIENT:
THANK YOU FOR CHOOSING OUR CENTER FOR YOUR DERMATOLOGICAL NEEDS.

YOUR APPOINTMENT IS SCHEDULED FOR: ___________________________________________________
IN THE: _____: DAYTONA BEACH OFFICE

_____: PORT ORANGE OFFICE

ENCLOSED ARE THE PATIENT INFORMATION SHEETS THAT YOU REQUESTED.

PLEASE BRING THESE FULLY COMPLETED FORMS, ALONG WITH YOUR INSURANCE CARD (S), AND DRIVER’S
LICENSE (OR PHOTO ID) WITH YOU TO YOUR SCHEDULED APPOINTMENT.

PLEASE ARRIVE AT LEAST 15 MINUTES BEFORE YOUR APPOINTMENT.
IT IS IMPORTANT THAT YOU NOT WEAR ANY COLOGNE (OR PERFUME) TO OUR OFFICE.
YOU WILL BE RESPONSIBLE FOR ANY CO-PAY OR DEDUCTIBLE AT THE TIME OF THE SERVICE (CASH, DEBIT OR CREDIT
CARD). WE DO NOT ACCEPT CHECKS.
ALL MINORS MUST BE ACCOMPANIED BY A PARENT FOR THEIR INITIAL VISIT. IF A LEGAL GUARDIAN, THEN WE
MUST HAVE A COPY OF THE LEGAL PAPERS AND/OR POWER OR ATTORNEY (POA) PAPERS AT THE TIME OF THE
SERVICE.

IF YOU HAVE ANY QUESTIONS, PLEASE CALL.
THANK YOU.


HELLER DERMATOLOGY CENTER
PATIENT INFORMATION SHEET
PLEASE PRINT CLEARLY AND COMPLETE IN FULL
PATIENT NAME:____________________________________________________________ TODAY’S DATE:________________________ DATE OF BIRTH:___________________AGE:______SEX:______DRIVER’S LICENSE STATE & #_______________________________ RACE:__________________________________ ETHNICITY:_________________________ PREFERRED LANGUAGE:__________________________ MAILING ADDRESS:________________________________________________________________________________________________ CITY:_____________________________________________________STATE:_____________ZIP CODE:________________________ HOME PHONE: (______)______________CELL PHONE: (_____)_________________SOCIAL SECURITY#________________________ WORK PHONE: (______)________________________EXT#_________ EMPLOYER NAME:_____________________________________ MARITAL STATUS: MARRIED_____ SINGLE_____ OTHER:_____ E-MAIL ADDRESS:_____________________________________ SPOUSE’S NAME___________________________________SS#____________________________DATE OF BIRTH:_________________ PRIMARY CARE PHYSICIAN:____________________________________________PHONE NUMBER#__________________________
REFERRING SOURCE:___________________________________________________PHONE NUMBER#__________________________
IF YOU ARE A STUDENT, CHECK ONE:
NAME OF YOUR SCHOOL:_________________________________________________________________________________________ STUDENT’S PERMANENT / PARENT’S NAME AND ADDRESS:_________________________________________________________ FOR EMERGENCY CONTACT, WE NEED THE NAME AND PHONE NUMBER OF SOMEONE WHO DOES NOT LIVE WITH YOU.
NAME:________________________________RELATIONSHIP:__________________PHONE NUMBER: (_____)__________________ ADDRESS:___________________________________CITY:_______________________STATE:__________ZIP CODE:______________ NEAREST RELATIVE NOT LIVING WITH YOU. NAME:________________________________________________________________
RELATIONSHIP:_________________________________PHONE: (_____)___________________________________________________ ADDRESS:__________________________________CITY:_______________________STATE:__________ZIP CODE:_______________ PRIMARY INSURANCE INFORMATION. WE WILL NEED TO MAKE COPIES OF ALL OF YOUR HEALTH INSURANCE ID
CARDS, PRIMARY AND SECONDARY (IF APPLICABLE). PLEASE COMPLETE THE FOLLOWING ALSO.
NAME OF PRIMARY INSURANCE COMPANY:______________________________________________________________________ INSURANCE ID#_____________________________________________POLICY OR GROUP#________________________________ NAME OF INSURED (IF DIFFERENT FROM PATIENT):__________________________RELATIONSHIP:____________________
INSURED’S DATE OF BIRTH:________________________________SS#______________________SEX:_______________________ INSURED’S ADDRESS:____________________________________CITY:__________________STATE:______ZIP CODE:_________ INSURED’S EMPLOYER:__________________________________WORK PHONE: (_____)_______________EXT:_______________ EMPLOYER’S ADDRESS:__________________________________CITY:__________________STATE:______ZIP CODE:_________ DO YOU HAVE A SECONDARY INSURANCE? YES_____ NO_____
***** IF YOU PROVIDE US WITH INCORRECT OR INVALID INSURANCE INFORMATION
AND WE NEED TO RE-ENTER AND RE-SUBMIT YOUR CORRECTED INSURANCE INFORMATION,
THERE WILL BE A $20.00 ADMINISTRATIVE CHARGE FOR EACH CLAIM REFILED***** _____________________
(PATIENT’S INITIALS)
PLEASE CONTINUE TO THE OTHER SIDE OF THIS FORM. THANK YOU. FINANCIAL POLICY OF THE HELLER DERMATOLOGY CENTER

As your physician, we are committed to providing you with the best possible medical care. In order to achieve this goal, we need your assistance, and your
understanding of our payment policy.
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. We accept cash, debit cards and credit cards (Visa, MasterCard, Discover &
American Express). In some cases, we will accept a check with prior approval. Returned checks are subject to a service charge of $35.00 (or 5% of the face
value of the check, whichever is greater), any bank fees and you will lose your privilege to write checks in our office.
PRIVATE INSURANCE COMPANIES THAT WE "ARE" A PROVIDER WITH. Co-payment, co-insurance and deductible must all be paid at the
time of service. If we are unable to verify your insurance coverage, you will responsible for payment in full today and we will give you the appropriate papers
to file for possible reimbursement. Because we are under contract with your current insurance company, we will file your insurance claim. If payment is not
received from your insurance company within a reasonable time (90 days), the full balance will be transferred to the responsibility of the patient (or guardian).
PRIVATE INSURANCE COMPANIES THAT WE "ARE NOT" A PROVIDER WITH. You will be responsible for payment in full at the time of
service and our office will give you the necessary forms so that you may file for reimbursement.
MEDICARE. Your deductible and 20% of the allowable charges are due at the time of service. Since we are a Medicare provider we will file your Medicare.
If we do not know the Medicare allowable charge for a specific service, we will bill you after Medicare processes the claim. Please bring your Medicare
Explanation of Benefits (EOB) showing you have met your deductible.
CHILDREN OF DIVORCED PARENTS. Payment will be due from the parent that is with the child today no matter who is responsible by order of the
divorce decree.
MISSED APPOINTMENTS. We ask for 24 hours notice to cancel an appointment. Failure to call may result in a charge to your account and /or loss of any
deposit for that appointment. Patients who do not call to cancel appointments may be discharged from the practice after the third no-show.
FINANCIAL AGREEMENT. We will gladly discuss your proposed treatment and do our best to answer any questions relating to your insurance. You must
realize, however, that:
1. Your insurance is a contract between you, your employer (possibly), and the insurance company. We are not party to that contract.
2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not
cover (such as yearly physicals, cosmetic procedures, etc.).
We must emphasize that as your medical care providers, our relationship and concern is with you and your health, not your insurance company. ALL
CHARGES ARE YOUR RESPONSIBILITY FROM THE DATE SERVICES ARE RENDERED. On any balance on your account after 90 days,
including those that your insurance has not paid, collection action will be taken. We realize that emergencies do arise and may affect timely payment of
your account. If such extreme cases do occur, please contact us promptly for assistance in the management of your account.
If it becomes necessary to collect any sum due through an attorney (or collection agency), then the patient agrees to pay all reasonable costs of collections ($25
monthly fee as of 2013), including attorney's fees, whether suit is filed or not. Returned checks are subject to a service charge of $35.00 (or 5% of the face
value of the check, whichever is greater), any bank fees and you will lose your privilege to write checks in our office.
If you have any questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help
you.

METHOD OF PAYMENT: CASH____, DEBIT____, CREDIT CARD____. VISA, MASTERCARD, DISCOVER, AMEX
NO CHECKS ARE ALLOWED.
I have read and understand the Financial Policy.
____________________________________________________________
Signature (Patient, Guardian, or Power of Attorney) ____________________________________________________________ HELLER DERMATOLOGY CENTER
PATIENT QUESTIONNAIRE AND HISTORY
TODAY’S DATE:__________________________________

NAME:__________________________________________
DATE OF BIRTH:_________________________________

HEIGHT:_____________
WEIGHT:___________

PLEASE LIST PAST SURGICAL HISTORY AND ANY CHRONIC ILLNESSES:
(If you have no past surgical history or chronic illnesses, check here:____________)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
PLEASE CHECK BELOW ONLY IF IT APPLIES TO EITHER YOURSELF OR A RELATIVE (Father/Mother/Brother/Sister):

Relative
Relative

1) Recent Weight Loss__________ ___
18) Kidney / Bladder_____________________________ ___
2) Migraine Headache__________ ___
19) Neurological_________________________________ ___
3) Convulsions________________ ___
20) Arthritis____________________________________ ___
4) Eye Disease_________________ ___
21) Osteoporosis_________________________________ ___
5) Hearing Disorder____________ ___
22) Bleeding Disorder____________________________ ___
6) Nose Bleeds_________________ ___
23) Diabetes____________________________________ ___
7) Sinus / Throat Infection______ ___
24) Mental Illness_______________________________ ___
8) Angina / Chest Pain_________ ___
25) Depression__________________________________ ___
9) Heart Attack_______________ ___
26) Cataracts?_____________Glaucoma?___________ ___
10) High Blood Pressure_________ ___
27) SKIN CANCER: MELANOMA?____OTHER?___ ___
11) Stroke_____________________ ___
28) JOINT REPLACEMENT?____________________ ___
12) High Cholesterol____________ ___
29) HEART VALVE DISORDER?________________ ___
13) Lung Disease_______________ ___
30) Alcohol / Drug Abuse_________________________ ___
14) Stomach Disorder___________ ___
31) Hepatitis B?__ C?___ Other Liver Disease?______ ___ ___
15) Bowel Problems____________
32) Blood Transfusion___________________________ ___
16) Anemia___________________
33) HIV history?________________________________ ___ ___
17) RHEUMATIC FEVER______
34) Other:_____________________________________ ___

LIST ALL DRUG ALLERGIES:
(If you have no known allergies, check here:__________)

__________________________________________
______________________________________
___________________________________________

__________________________________________
______________________________________
___________________________________________

LIST ALL THE NAMES OF ANY MEDICATIONS YOU CURRENTLY TAKE OR USE (EVEN IF ONLY AS NEEDED):
(If you take no medications, check here:_______) ______________________________
______________________________________

_________________________________________
_______________________________________
____________________________________________

_________________________________________
_______________________________________
____________________________________________

_________________________________________
_______________________________________
____________________________________________

_________________________________________
_______________________________________
____________________________________________

SOCIAL HISTORY:
CURRENTLY
PREVIOUSLY
Cigarettes
Yes___ No___
Yes___ No___
(IF YES, HOW MUCH______________________________)
Yes___ No___
Yes___ No___
Coffee / Tea
Yes___ No___
Yes___ No___

FOR WOMEN ONLY:
Last Menstrual Period:_______________
ARE YOU CURRENTLY PREGNANT? YES______ NO______
Number of pregnancies:_______________
Taking Birth Control? Yes____ No____
TUBAL LIGATION?______________ HYSTERECTOMY?_________________________

PATIENT (OR PARENT / GUARDIAN) SIGNATURE:______________________________________________________________________
HELLER DERMATOLOGY CENTER
LIFETIME AUTHORIZATION, INSURANCE ASSIGNMENTS
AND AUTHORIZATION TO RELEASE INFORMATION
RELEASE IN INFORMATION - I, the below named patient, do hereby authorize any physician examining and/or treating me to release to any third payer (such as an insurance company or governmental agency, example: Blue Cross/Blue Shield or Medicare) any medical condition and records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment for such treatment and/or diagnosis. II. PHYSICIAN INSURANCE ASSIGNMENT - I, the below named subscriber, hereby authorize payment directly to any physician examining or treating me of any group and/or individual surgical and/or medical benefits herein specified and otherwise payable to me for their services as described but not to exceed the reasonable and customary charge for these services. III. MEDICARE - Patient's certification authorization to release information and payment request. I certify that the information given by me in applying for payment under Title XVIII/XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I hereby certify all insurance pertaining to treatment shall be assigned to the physician treating me. IV. I PERMIT A COPY OF THESE AUTHORIZATIONS AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL THAT IS ON FILE AT THE PHYSICIAN'S OFFICE. This assignment will remain in effect until
revoked by me in writing.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not
a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of
the charge. I understand it's my responsibility to pay any deductible amount, co-insurance, or any other balance not
paid for my insurance or third payor within a reasonable period of time not to exceed 90 days.
If this account is assigned to any attorney for collections and/or suit, the patient (or parent/guardian) agrees to pay all
reasonable attorneys' fees and costs of collection.

Date:____________________
Signature of Patient (Parent/Guardian/Subscriber):_____________________________________________

Original Signature on File at Physician's Office
SECONDARY INSURANCE SIGNATURE

I request that payment of authorized secondary (Medigap for Medicare patients) benefits be made on my behalf to
Heller Dermatology Center for any services furnished to me by Dr. Heller. I authorize any holder of medical
information about me to release to Dr. Heller any information needed to determine benefits or the benefits payable for
related services.
Date:____________________
Signature of Patient (Parent/Guardian/Subscriber):_____________________________________________

Heller Dermatology Center
Jeffrey J. Heller, D.O.
NOTICE OF PRIVACY PRACTICES
WRITTEN ACKNOWLEDGEMENT FORM

I, ______________________________________________, feel I have complete understanding
(PRINT Patient Name or Parent/Guardian or POA)
and/or received a copy (***) of Jeffrey J. Heller’s Notice of Privacy Practices regarding
patient:__________________________________________________ / __________________________.
(PRINT Patient Name)
Patient or Parent/Guardian or POA SIGNATURE____________________________________________
Date signed:____________________________________________ *** Our privacy practices booklet is available to read in the reception area or you may ask the front
desk personnel for a copy ***
*************************************************************************************
I authorize Jeffrey J. Heller, D. O. to release my (patient’s) medical
information to:
Please print

Name & specify relationship to patient:_____________________________________Phone#________________
Name & specify relationship to patient:_____________________________________Phone#________________
MYSELF ONLY: Initial here:__________ Phone#________________________________________________
(This authorization will expire one (1) year after the date on which the authorization was signed)
HELLER DERMATOLOGY CENTER
COSMETIC INTEREST QUESTIONNAIRE
Patient name:___________________________ E-mail address:_______________________________ Today’s date:___________________________ Health issues and procedures or products of interest to you (please check all that apply). __ BOTOX Cosmetic (Botulinum Toxin Type A) __ Other, Please Specify:___________________________________________________________ When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age. Younger Than 1 2 3 4 5 When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles. DIRECTIONS TO DAYTONA OFFICE
HELLER DERMATOLOGY CENTER
511 NORTH CLYDE MORRIS BLVD.
DAYTONA BEACH, FL 32114
386-239-8700
FROM I-95
GET OFF 95 AT THE ISB / US92 EXIT (EXIT # 87). HEAD EAST TO CLYDE MORRIS BLVD. AND TURN LEFT. WE ARE
JUST PAST THE THIRD LIGHT (DUNN AVENUE) ON THE RIGHT.
FROM SOUTH DAYTONA / PORT ORANGE:
TAKE CLYDE MORRIS NORTH. GO PAST “ISB” AND CONTINUE PAST ANOTHER 3 LIGHTS. WE ARE JUST PAST
DUNN AVENUE (3RD LIGHT) ON THE RIGHT.
FROM INTERNATIONAL SPEEDWAY BLVD (ALSO KNOWN AS “ISB” OR US92):
TURN NORTH ON CLYDE MORRIS BLVD. AND GO PAST THREE LIGHTS. WE ARE JUST PAST THE 3RD LIGHT (DUNN
AVENUE) ON THE RIGHT.
FROM BEACHSIDE (DAYTONA):
TAKE MASON AVENUE WEST TO CLYDE MORRIS BLVD. AND TURN LEFT (SOUTH). WE ARE JUST BEFORE THE
NEXT LIGHT (DUNN AVENUE) ON YOUR LEFT.

FROM NEW SMYRNA BEACH / EDGEWATER (SOUTH OF DAYTONA):
TAKE US1 (RIDGEWOOD AVE) TO ISB AND TURN LEFT. GO TO CLYDE MORRIS BLVD. AND TURN RIGHT. WE WILL
BE JUST PAST THE THIRD LIGHT (DUNN AVENUE) ON THE RIGHT.
DIRECTIONS TO PORT ORANGE OFFICE
HELLER DERMATOLOGY CENTER
790 DUNLAWTON, SUITE D
WE ARE IN PORT ORANGE ONLY
ON THURSDAY AFTERNOONS,
BY APPOINTMENT

FROM I-95
GET OFF OF 95 AT THE PORT ORANGE EXIT (I DON’T KNOW THE EXIT #). TURN LEFT (HEADING EAST). GO
ACROSSED NOVA ROAD. WE WILL BE APPROX 4/10TH OF A MILE ON THE RIGHT (PORT ORANGE MEDICAL
CENTER) PAST NOVA.
FROM DAYTONA / ORMOND:
TAKE NOVA ROAD SOUTH TO DUNLAWTON AND TURN LEFT (EAST). WE ARE IN THE PORT ORANGE MEDICAL
CENTER WHICH IS APPROX. 4/10TH OF A MILE FROM NOVA. THE OFFICE IS ON THE RIGHT. WE ARE IN SUITE D
WHICH IS IN THE FRONT PART OF THE BUILDING….APPROX. IN THE MIDDLE.
FROM NEW SMYRNA BEACH / EDGEWATER:
TAKE US1 (AKA RIDGEWOOD AVENUE) NORTH TO DUNLAWTON AVENUE AND TURN LEFT. GO PAST THE POST
OFFICE (THAT IS ON YOUR RIGHT). WE ARE ON THE LEFT SIDE OF THE ROAD (SOUTH SIDE) IN THE PORT
ORANGE MEDICAL CENTER.
INTERNATIONAL SPEEDWAY BLVD (ALSO KNOWN AS “ISB” OR US92)

Source: http://www.hellerdermcenter.net/docs/FORM%20-%20ADULT%20PATIENT%20INFO%20SHEETS%20TO%20HANDOUT,%20FAX,%20MAIL%20OR%20EMAIL%20HIGHLIGHTED%20JUNE%202013.pdf