Patient Information Form

Patient Name

Preferred Name

Date of Birth

Sex

Male Female Other

SSN

Marital Status

Preferred Pronouns

Patient Address

Unit Number

City

State

ZIP

Please check the box to indicate your primary phone number:

Home Phone

Kindly provide number

Work Phone

Kindly provide number

Cell Phone

Kindly provide number

Email address

Race

American Indian/ Alaska Native Hawaiian/ Pacific Islander Asian White/Caucasian Black/ African American Unknown Declined Other

Ethnicity

Not Hispanic or Latino Hispanic or Latino Declined Unknown

Language

Emergency Contact Name

Relationship to Patient

Emergency Contact Home Phone

Cell Phone

Primary Care Physician

Referring Physician

Primary Pharmacy

Phone

Insurance Information

Primary Insurance Plan Name

Effective Date

Policy Holder

Policy Holder Date of Birth

Insurance ID

Group #

Claims Address

Secondary Insurance Plan Name

Effective Date

Policy Holder

Policy Holder Date of Birth

Insurance ID

Group #

Claims Address

Assignment and Release of Benefits

I hereby assign all medical and/or surgical benefits, to include Major Medical Benefits to which I am entitled, including Medicare, private insurance, and any other health plan to: Georgia Skin Specialists, P.C.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release medical information to secure payment.

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.

Signed

Date

Your information will be encrypted.