Patient Information Form

INSURANCE POLICY HOLDER

IF POLICY HOLDER IS DIFFERENT FROM PATIENT THEN PLEASE COMPLETE THIS SECTION

EMERGENCY CONTACT INFORMATION

MEDICAL RECORD DISCLOSURE

I authorize Eyre Dermatology Clinic to discuss the following aspects of my care with the following individual(s):

INSURANCE INFORMATION

PLEASE PROVIDE A COPY OF THE CARD TO THE RECEPTIONIST

Primary Insurance

Secondary Insurance

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

SKIN DISEASE HISTORY

Please list all current prescription medications

MEDICATION ALLERGIES

Please list all medication allergies

I hereby certify that the above information is true and correct to the best of my knowledge. I understand that while Eyre Dermatology Clinic contracts with many insurance companies, it is MY responsibility to verify with my insurance plan that the physician I am seeing is a participating provider. I further understand that Eyre Dermatology Clinic will bill my insurance as a courtesy to me. I authorize payment of medical benefits to Eyre Dermatology Clinic and physicians. If, however, my insurance does not cover the services, I will be financially responsible for the services rendered. I hereby authorize Eyre Dermatology Clinic to submit insurance claim forms along with medical records necessary to obtain payment from my insurance company. I understand that I am responsible for all charges regardless of insurance coverage. It is my responsibility to provide Eyre Dermatology Clinic with correct and current information. I understand that co-pays are due at the time of service. If my account becomes more than 90 days past due, the account will automatically be turned over to a collections agency, and additional charges will be assessed. Blood tests and pathology consults are not billed from Eyre Dermatology Clinic. They are billed from the facilities that the specimens are sent to. These facilities will bill your insurance for tests ordered, but you may still receive a bill for deductibles and co-pays as required by your insurance. By signing this, I authorize Eyre Dermatology Clinic to provide these facilities with the necessary information to process claims on my behalf. I acknowledge that photo IDs taken are used to assist in patient recognition per HIPAA guidelines. By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize Eyre Dermatology Clinic to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, balances due, lab results, or any other healthcare related function. I also authorize my Eyre Dermatology Clinic to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events. I consent to the receiving multiple messages per day from my healthcare provider, when necessary. I consent to allowing detailed messages being left on my voice mail, answering system, or with another individual, if I am unavailable at the number provided by me. I have received a copy of the HIPAA policy. I authorize treatment.

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