Patient Demographic Form

INSURANCE INFORMATION

PRIMARY

SECONDARY

I understand that my insurance policy is a contract between myself and the insurance company and Affiliated Dermatologists of VA (ADOV) is not a party to that contract. I am ultimately responsible for unpaid balances and non-covered services. I am responsible for informing the office of all changes to my information and insurance PRIOR to my appointments. Insurance must be in force and verifiable at time of treatment. If my insurance company requires a referral, it is my responsibility to obtain one PRIOR to my appointment. If I do not have insurance or a referral, I agree to pay in full at the time of the appointment. I hereby assign all insurance benefits for services rendered, otherwise payable to me, directly to ADOV from Medicare or my private insurance. I authorize ADOV to release medical information to my insurance company, its agents or any third party for use in determining my benefits. If my account enters a delinquent status, I agree to pay all costs of collections including attorney fees and court fees. If my account enters court collection status, I understand that I am no longer a patient of record. I understand that the fee for a returned check is $35. AS A COURTES Y ONLY, we will attempt to confirm your appointment prior to the date. ADOV cannot guarantee a reminder call. I understand that ADOV charges a minimum fee of $50 for appointments missed or cancelled without 24 hours notice. I agree to pay such fee. * ADOV will maintain patient records for a minimum of six years following the last visit, barring any exceptions where we may be required to keep them longer.

By signing below I indicate my understanding and agreement with the policies listed above and authorize Affiliated Dermatologists of Virginia to render treatment to the patient named.

DISCLAIMER: 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.