Patient Registration Form

Please correct the errors described below.

PAYMENT REQUESTED AT TIME OF SERVICE - UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical/medical benefits to Zaladonis Dermatology Associates for services rendered by providers in person or under supervision. I understand that I am financially responsible for any balance not covered by my insurance.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Zaladonis Dermatology Associates to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.

MEDICARE - MEDICAID

I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be valid as the original.

HISTORY AND INTAKE FORM

Past Surgical History (check all that apply)

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SOCIAL HISTORY (check all that apply)

PHARMACY:

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