BAR Medicare Patient Registration Form

Today's Date:

First Name:

Middle Name:

Last Name:

Sex:

Male Female

Mailing Address:

City:

State:

Zip:

Email Address:

Preferred Language:

Race:

White

Native American

Asian

Black

Native Hawaiian

Other

Other:

Home Phone:

Please select:

Work Cell

Phone Number:

Social Security Number:

Ethnic Group:

Hispanic or Latino Not Hispanic or Latino Unknown

Marital Status:

Date of Birth:

Age:

Spouse's Name:

(*required if Medicare is secondary and your spouse carries the primary insurance)

Date of Birth:

This office is required to keep your signature on file authorizing us to file claims to Medicare for you and to release information to that payer if they require it for the proper consideration of a claim. Please read and sign the following statement:

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to Bardstown Dermatology PSC, who accepts assignment. Regulations pertaining to Medicare assignment apply.

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.

Signature (required) as it appears on Medicare Card :

Date:

If you have a supplemental policy and it is a medigap policy (Medicare Carrier automatically "crosses over", sends info to 2nd policy), we are required to keep a separate signature on file:

I request authorized benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to the above medigap carrier any information needed to determine these benefits or the benefits payable for related services.

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.

Signature (required) as it appears on Supplement/Secondary Card:

Date:

Referral Information: I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to Bardstown Dermatology, PSC.

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.

Signature:

Date:

Please upload a photocopy of your insurance cards below

Insurance cards:

Add file

Please upload a file

Your information will be encrypted.