Patient Registration Form

Please correct the errors described below.

Patient Financial Policy Agreement

We are committed to providing you with quality healthcare and would appreciate your commitment to adhere to this Financial Policy Agreement. Please read this policy carefully and sign the Acknowledgement section at the bottom of this form. Please do not hesitate to ask a member of our staff if you have any questions.

For Medicare Recipients ONLY

I request payment of authorized Medicare benefits be made directly to Dr. Valerie G. Davis of Davis Dermatology for any services provided to me. I authorize the release of information to Medicare and my secondary insurance to assist me in the processing and payment of all claims. Dr. Valerie Davis agrees to accept Medicare assignment and I will be responsible for any deductible, coinsurance or any non-covered services determined by Medicare.

FOR ALL PATIENTS Insurance and Payment

1. All patients are required to provide valid, current proof of insurance and a copy of their driver’s license. Failure to do so might result in denial of payment from your insurance plan and the balance will be your responsibility.

2. Payment of all deductibles, copays, coinsurances, and other patient financial responsibilities are required at each office visit unless payment arrangements have been made in advance. *Your health policy is a contract between you and your insurance company and we are NOT a party to that contract.*

3. We will submit your claim and assist you in any reasonable way to help get your claim paid. It is your responsibility to provide your insurance company with any requested information in a timely manner. You are responsible for services that are NOT COVERED by your plan.

4. If we do NOT participate with your insurance plan, we will submit a claim to your insurance carrier as a courtesy to you but PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDEREED.

5. Self-Payment: Payment is expected at the time services are rendered unless prior arrangements have been made.

6. Medicaid: (if applicable) it is the patients responsibility that all proper authorizations have been obtained from your Medipass provider, otherwise payment is expected at the time services are rendered.

7. Care for minors: A parent or legal guardian MUST accompany minor patients on the patient’s first visit. The accompanying adult is responsible for payment of the account, according to the policy outlined above.

Please Complete Other Side

Note: This policy applies only to Davis Dermatology

  • All lesions removed will be sent to a pathology lab.
  • Payment for all non-medically necessary cosmetic services is expected at the time of the visitand will not be submitted to your insurance.

By signing below, I acknowledge that I have read, understand, and agree to the above Patient Financial Policy Agreement.

I authorize my insurance benefits to be paid directly to Dr. Valerie G. Davis and I also authorize the release of my medical information to my insurance company when required to facilitate payment of a claim.

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.

Previous Health History

Patient Information Record

Please place a check next to the phone number you would like to be contacted on.

If patient is under 18 yrs. of age please complete the following section

ALL PATIENTS please complete below

Cancellation and No Show Fee Policy

Your appointment time is reserved especially for you and each time a patient misses an appointment without providing appropriate notice, another patient is prevented from receiving care. Please contact our office at 386-423-2218 no less than 24 hours prior to your scheduled office visit appointment time and 48 hours prior to a scheduled procedure/surgery appointment if you are unable to keep your appointment.

If you check in for your appointment more than 15 minutes past your scheduled appointment time, you may need to be rescheduled to the next available appointment time and date and the above no show policy will be enforced.

Davis Dermatology P.A. reserves the right to charge a $25.00 fee for all missed (Late Cancellation/No Show) office visit appointments and a $75.00 fee for all missed (Late Cancellation/No Show) procedure /surgery appointments.

These fees are not covered by your insurance carrier and must be paid prior to your next appointment. Multiple “no shows” or same-day cancellations in a six month period may result in termination from our practice.

We appreciate your understanding and cooperation as we strive to best serve the needs of all our valued patients.

By signing below, you acknowledge that you have received this notice and understand our practice's policy.

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.

Patient Consent for Use and Disclosure of Protected Health Information

With my consent, Valerie G. Davis, M .D. may use and disclose protected health information about me to carry out treatment, payment, and healthcare operations. Please refer to the Notice of Privacy for a more complete description of such uses and disclosures. I have the right to review the Privacy Notice prior to signing this consent; it is available at the front desk. The practice reserves the right to revise the Privacy Notice at any time.

With my consent, Valerie G. Davis, M .D. and/or her staff may send mail to my home or other designated location(s) that assist the practice in carrying out treatment, payment, and other healthcare operations.

I have the right to request that Valerie G. Davis, M.D. restrict how she uses or discloses my protected health information and to carry out my treatment, payment, and healthcare operations. Please note, the practice is not required to agree to my requested restriction, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Valerie G. Davis, M .D. the use and disclosure of my protected health information and to carry out my treatment, payment, and healthcare operations.

I may revoke my consent in writing except to the extent the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Valerie G. Davis, M.D. may decline to provide treatment to me.

You have the right to choose to whom we may release your protected health information. Please check and initial next to those persons to whom you wish your protected health information be released to.

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.

Please check any item you would like more information about today.

  • Pain relief
  • Increased strength and mobility
  • Improved memory, mood, and brain function


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.

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