Legally the responsible party is the person signing the financial agreement and/or the patient. Regarding patients up to the age of 26: We are aware there are reasons patients wish to have financial statements sent to an additional person(s). If you want the statement sent to someone other than the patient/responsible party, please list the name, address, DOB, and relationship to the patient below. The practice reserves the right to default to the primary subscriber.
By signing below, I authorize treatment from Skin Cancer & Dermatology Center. I authorize my insurance benefits to be paid directly to the provider/practice. I understand that I am financially responsible for any balance. I also authorize the Skin Cancer & Dermatology Center or my insurance company to release any information required to process my claims. The above information is accurate to the best of my knowledge.
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.
Your information will be encrypted.
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