New Registration Form

Today's Date:

Salutation:

Mr. Mrs. Miss Ms.

Name:

Marital Status:

Single Married Divorced Separated Widowed

Street Address:

City:

State:

Zip Code:

Home Phone:

Cell:

Social Security #:

Birth Date:

Gender:

Male Female

Email:

Referring Physician:

Primary Care Physician:

Primary Insurance:

ID#:

Group#:

Secondary Insurance:

ID#:

Group#:

(PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD TO THE RECEPTIONIST)

How did you hear about us?

Family/Friend

Patient

Insurance

Location

Online/Radio Ad

Search Engine

Website

Yellow Pages

Emergency Contact Name:

Relationship:

Home Phone:

Cell:

The above information is true to the best of my knowledge, I authorize my insurance benefits be paid directly to the physician, I understand that I am financially responsible for any balance, I also authorize Cosmopolitan Dermatology, Inc. Or Insurance company to release any information required to process my claims.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient /Parent or Guardian Signature:

Date:

Please Read and Sign Back

PATIENT FINANCIAL LIABILITY FORM

INSURANCE

Patients are responsible for providing accurate and timely insurance information to our office. Patients will be held financially liable for services rendered if the correct insurance information is not provided
within the required filing period for their insurance. Verification of benefits or prior authorization is not a guarantee that an insurance carrier will pay a claim. The insurance carrier makes final determination upon receiving the claim, based upon the plan’s level of coverage and associated policies. Denied claims become the responsibility of the patient. Patients are fully responsible for obtaining any necessary referral from another physician before the appointment time. Insurance claims denied due to lack of referral will become the patient’s responsibility.

Co-payments are due and payable at the time of service. If we are unsure of copay liability, we will bill the insurance first then the patient will be billed for any applicable co-payments. Patient agrees to pay all deductibles, coinsurance and services deemed “patient responsibility” as identified by the insurance carrier. Payment in full is due upon receipt of statement.

Cosmopolitan Dermatology, Inc. accepts Visa, Mastercard, Discover, American Express, checks, or cash. Checks returned for non-payment will be subject to additional fees. Unpaid patient balances may be placed with an outside collection agency if payment is not made within 120 days. This may adversely affect your credit. Non-emergent medical services may be denied until delinquent balances are paid.

COSMETIC SERVICES

All cosmetic services are payable in full at the time of service. A $75.00 deposit is required at the time of scheduling appointment.

NO-SHOW APPOINTMENTS

If you are unable to keep your appointment, please notify our office no less than 24 hours before your appointment. Messages are acceptable and can be left at all times during evening and weekends. Cosmopolitan Dermatology may assess a $35.00 fee for an appointment that is missed without adequate notice.

I have read the above information and agree to the terms contained therein:

Patient’s Name:

Parent/Guardian Name (If patient is a minor):

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient or Parent/Guardian Signature:

Date:

Today’s Date:

Patient Name:

Date of Birth:

Pharmacy Name:

Pharmacy Location:

Pharmacy Phone Number:

Medications (Please list all Prescription and OTC Medications):

Allergies:

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