PATIENT NAME: First Middle Last (As Printed on Insurance Card) SEX: M F BIRTHDATE: AGE: PATIENT SSN: -- HOME ADDRESS: CITY: STATE: Maryland Virginia District Of Columbia --------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington West Virginia Wisconsin Wyoming ZIP: -
PREF. CONTACT #: - - ext: HOME PHONE: - - WORK PHONE: - - ext: CELL PHONE: - - PREFERRED # TO CALL REGARDING LABS/APPOINTMENTS/RESULTS - - ext: MAY WE LEAVE A MESSAGE IF UNABLE TO REACH YOU? (MAY CONTAlN PERSONAL INFO): YES NO
IF REQUESTED, MAY WE DISCUSS YOUR MEDICAL CARE WITH A FAMILY MEMBER? YES NO
IF YES, PLEASE CHECK: Spouse Partner Parent Child Other
EMPLOYER: OCCUPATION:
SPOUSE/PARTNER/PARENT NAME: WORK PHONE: SPOUSE/PARTNER/PARENT EMPLOYER:
MAY WE EMAIL YOU PERIODICALLY WITH UPDATES AND NEWS ON THE PRACTICE? Yes NO (or already receive updates) YOUR EMAIL:
HOW DID YOU HEAR ABOUT US?
PRIMARY CARE PHYSICIAN PHONE # - - ext: NO PRIMARY CARE PHYSICIAN
REFERRING PHYSICIAN PHONE # - - ext: SELF REFERRED
NO INSURANCE (self pay)
PERSON RESPONSIBLE FINANCIALLY FOR ACCOUNT (SELF, SPOUSE, PARENT OR LEGAL GUARDIAN): SELF NAME: SSN: - - BIRTHDATE: RELATIONSHIP TO PATIENT: BILLING ADDRESS: CITY: STATE: Maryland Virginia District Of Columbia --------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington West Virginia Wisconsin Wyoming ZIP: - PREF. CONTACT #: - - ext: HOME PHONE: - - WORK PHONE: - - ext: CELL PHONE: - -
IN THE EVENT OF AN EMERGENCY, PLEASE CONTACT: NAME: RELATIONSHIP TO PATIENT: PREF. CONTACT #: - - ext: HOME PHONE: - - WORK PHONE: - - ext: CELL PHONE: - -
Assignment of Benefits: I hereby authorize the physicians and staff of Dermatology & Clinical Skin Care Center and Rockledge Surgical Center to render treatment to me/my dependents. I further authorize Dermatology & Clinical Skin Care Center and Rockledge Surgery Center to release my personal health information for purposes of treatment, payment or operations by phone, mail or fax. I assign and authorize payment of medical/surgical benefits directly to Dermatology & Clinical Skin Care Center and Rockledge Surgery Center, Inc.
Financial Policies: I understand that any unpaid balances or non-covered services will be my responsibility. I understand that if I provide incorrect or expired insurance information I will assume full financial responsibility for all charges incurred. I understand I will be charged a missed appointment fee of $25.00 per visit should I fail to provide 24 hours notice of cancellation or rescheduling. I understand that if my copay is not paid at the time of service, I will be charged a $10 billing fee. I understand cosmetic appointments will be charged a minimum fee of $75 for failure to provide 24 hours of cancelation, and that a credit card deposit will be collected at the time of scheduling. I also understand I will be charged a $30.00 collections fee should my account be referred to a collections company for non-payment and a $35.00 fee for any and all returned checks. We accept cash, checks, MasterCard, Visa and American Express as forms of payment.
By my signature, I certify that the information I have reported with regard to my insurance coverage is correct and acknowledge that I have read and understand the above financial policies (if patient is a minor, signature of responsible party):
SIGNATURE: DATE: Initial: DATE: Initial: DATE: Initial: DATE:
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT 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 authorize the employees of Dermatology & Clinical Skin Care Center and Rockledge Surgery Center and other contracted entities to view this information and to use this information to:
I have been offered a copy of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its 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.
Patient Name: Relationship to patient: Self Parent Guardian Other
SIGNATURE: DATE: