New Patient Privacy & Consent

New Patient Privacy & Consent
Patient Name (include title, first, middle and last)*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
ACKNOWLEDGEMENT OF RECEIPT

(NOTICE OF PRIVACY PRACTICES)
Southeastern Skin Cancer & Dermatology
8331 Madison Boulevard, Suite 300
Madison, Alabama 35758
(256) 705-3000
I understand that, under the Health Insurance & Portability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that the information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. HIPPA forms are available for download on our website forms page or in our office. I understand that the organization (Southeastern Skin Cancer & Dermatology) has the right to change the Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Relationship to Patient*
Typed Electronic Signature*
SOUTHEASTERN SKIN CANCER & DERMATOLOGY
CONSENT FORM FOR MINOR SURGERY • CRYOSURGERY • BIOPSY
During your visit, the dermatologist may need to perform cryosurgery or a skin biopsy to treat or evaluate your skin condition. Please review and sign the consent form below. You will be given ample time to discuss the procedure if the doctor determines cryosurgery or a biopsy is necessary. This will serve as a standing consent for this and any and all future treatments (only of these types), however verbal consent will ALWAYS be obtained PRIOR to any treatment.

CONSENT FOR: CRYOSURGERY OR BIOPSY PROCEDURE

PURPOSE:
(1) A biopsy is a surgical procedure used to obtain a sample of tissue for microscopic examination to aid the physician in diagnosis. The entire lesion may not be removed in this procedure. Further medical or surgical treatment may be needed when the diagnosis is made.

(2) Cryosurgery is the use of liquid nitrogen to freeze the skin lesions that respond well to sub-zero temperatures. The process is commonly used to freeze precancerous lesions known as actinic keratosis or solar keratosis. The treatment is also used to freeze the virus infections that cause many common warts as well as other lesions.

PROPOSED TREATMENT:
(1) I understand that a biopsy requires obtaining a sample of tissue and is a surgical procedure. As in any surgical procedure, there are certain risks that include but are not limited to bleeding, post-operative pain, infection, reactions to sutures, anesthetics or topical antibiotics, and scarring. Although all reasonable efforts will be made to minimize the possibility of these potential complications, no guarantees can be made since many factors beyond the control of the physician (such as the degree of sun damage or patient compliance with post-operative instructions) affect the ultimate healing.

A pathologist will examine the tissue obtained in this biopsy procedure to assist in providing a specific diagnosis for you. I understand I may receive a separate bill from the pathologist or laboratory for this microscopic examination.

(2) Complications of applying liquid nitrogen to the skin may include but is not limited to skin irritation, redness, temporary discomfort, blistering, infection, or permanent loss of pigmentation. After the lesion has been treated, most patients develop a crust or scab that lasts for 1-2 weeks.

OTHER ACKNOWLEDGEMENT DISCLOSURE:
I am able to read and understand English. I understand that I will have the opportunity to discuss my procedure with the physician or other professional who is to perform the procedure and have all of my questions answered to my satisfaction.

PHOTOGRAPHIC CONSENT:
I authorize and consent to the taking of a series of photographs of the surgical areas for the use of Southeastern Skin Cancer & Dermatology for my chart, in lecturing, or in print (medical journal or text)/video (medical education purposes) publication. NO IDENTIFYING PATIENT INFORMATION WILL BE INCLUDED.
This form saves you time and paperwork once in the exam room to improve efficiency. IF EVER NEEDED, ANY OF THESE PROCEDURES WILL ALWAYS BE REVIEWED AND APPROVED BY YOU BEFORE BEING PERFORMED. ALSO, THIS DOES NOT COMMIT YOU TO ANY FUTURE PROCEDURE, YOU ALWAYS HAVE FULL CONTROL OF YOUR HEALTHCARE DECISIONS, BUT IT PROVIDES INFORMATION SHOULD ANY OF THE ABOVE BE RECOMMENDED.
Typed Electronic Signature*
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New Patient Privacy & Consent

ACKNOWLEDGEMENT OF RECEIPT