DERMATOLOGY INSTITUTE: REGISTRATION FORM

706 W. CENTER STREET * DUNCANVILLE, TX 75116 * 972-780-0707

 

Patient Name:______________________________________________________________________

                                                FIRST                  MIDDLE              LAST

 

Age:______ Date of Birth:____/____/____                  Social Security#______/_____/______

 

Address:___________________________________________________________________________

                             STREET                        CITY                    STATE                 ZIP   

 

PHONE MESSAGES WILL ONLY BE LEFT AT HOME OR ON CELL PHONE NUMBERS

Home Phone #: (_____)___________________ Cell phone #: (_____)________________

Work Phone #: (_____)___________________

 

Email addresses are confidential and will only be used for the purpose of providing you with practice updates and medical information

Email Address:_________________________________________________________________

 

How did you find out about us: (circle one)

Existing Patient    News Paper Ad    Vision Pack    Internet    Walk-in

 Primary care Physician:______________________________  Other:___________________________

 

Sex: (circle one)  Male  Female     Race: (circle one) White  Black  Asian  Hispanic  Other_______

 

Maritial Status: (circle one)  Single  Married  Widowed  Divorced

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Please list any person (such as, a friend, family member or other) that you give Dermatology Institute consent to discuss your medical information and/or inquire about appointments or billing.

Name________________________________ Relationship___________________________________

Name________________________________ Relationship___________________________________

Name________________________________ Relationship___________________________________

 

Please list an emergency contact person:__________________________________________________

Phone Number (____)______________________           Relationship_______________________________

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Primary Care Physician: Name__________________________________________________________

Address: ___________________________________________________________________________

Phone Number: (____)____________________

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IF PATIENT IS A MINOR, OR PATIENT IS NOT THE PRIMARY INSURANCE HOLDER, PLEASE FILL OUT THE INFORMATION BELOW

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Name of person that is legally responsible for this patient or primary insurance holder:

__________________________________________________________________________________

FIRST                            MIDDLE                                 LAST

Date of Birth:____/____/_____                 Social Security#:____/____/____

Billing Address:_____________________________________________________________________

                                      STREET              CITY          STATE                 ZIP

Home Phone #: (____)_______________   Cell Phone #: (____)________________ 

Work Phone #: (____)_______________

 

 

                                                  

Insurance assignment and release

 

Today, you have chosen to be seen as a patient for the treatment of your skin, hair or nail problems. We will file your insurance for you, however, we are now

required by all insurance companies, including Medicare, to inform you that your insurance company may decide that your medical condition is deemed not of

medical necessity, or that it is a cosmetic problem not requiring medical care.

 

 

If the patient is informed by us, that their insurance company is not

paying for their medical services, and the patient should disagree with this

decision, the patient will need to contact the insurance carrier directly.

 

By signing this form, you agree that you will pay for any medical

services rendered that your insurance does not cover within 30 days of receiving your statement from our office.

 

All patients are responsible for payment of their co-pay and/or deductible at the time of their visit. Co-pays are typically collected upon check in and deductibles are typically collected upon check out.

 

 

I, do, hereby state, that this consent form will apply indefinitely to all medical and surgical care provided at the:

DERMATOLOGY INSTITUTE

Bill V. Way, D.O., P.A.

 

This includes any dermatologists, resident, medical assistant, or any other

employee of Dermatology Institute until cancelled by me in writing. I authorize

release of any medical information necessary to process this medical claim. I

request payment of any government or private insurance benefits for medical

services performed on me  to be paid directly to Dermatology Institute.

 

                                                 

PRINTED NAME OF PATIENT

 

                                                                                                                              

PATIENT SIGNATURE                                                         DATE OF SIGNATURE

 

 

              

 

 

 

 

 

 

 

 

 

 

PRIVACY PRACTICES ACKNOWLEDGEMENT

 

In accordance with Federal Government HIPPA guidelines, I have

been provided the opportunity to review the Notice of Privacy Practices from the Dermatology Institute.

 

                                                                                          

PRINTED NAME OF PATIENT

 

                                                      

PATIENT DATE OF BIRTH

 

                                                                                                                                   

PATIENT SIGNATURE                                                              DATE OF SIGNATURE

 

 

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No SHOW / CANCELATION POLICY

 

If you are unable to keep your appointment, we ask that you notify us as soon as possible.  I understand that

A missed appointment fee of $50

will be charged for  appointments that are missed without prior notification.

 

 

 

                                                                                                                                                                                

PATIENT SIGNATURE                                                                  DATE OF SIGNATURE