Patient Registration Form

Please correct the errors described below.

Emergency Contact:

*MINORS ONLY*

LEGAL GUARDIAN PARENT INFORMATION FOR MINORS (17 YEARS AND YOUNGER)

I authorize the office of Richard A. Cirelli, MD, PC to provide medical and/or surgical care, including, but not limited to diagnostic testing and medically necessary treatments to the minor child when unaccompanied to an appointment. I understand payment is due when services are rendered and being the legal guardian/parent I am financially responsible for services rendered. By signing below, I acknowledge I have read, understand, agree and consent to the consent regarding minor child.

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.

INSURANCE INFORMATION

*INSURANCE CARDS MUST BE PRESENT AT THE TIME OF YOUR APPOINTMENT WITH PHOTO ID*

** The Affordable Care Act requires us to collect data consistent with standards set by the government for reporting. Please complete all requesting information. **

I authorize the release of any medical information necessary to process claims and hereby assign all benefits payable to Richard A. Cirelli, MD, PC dba SunWest Dermatology and Skin Cancer Treatment Center on my behalf for all services rendered. In the case that my insurance company reimburses me directly, I will submit payment from the insurance company directly to Richard A. Cirelli, MD, PC. I understand I am financially responsible for all charges for services rendered even in cases my insurance denies payment for services rendered. I authorize the release of my medical information to other physicians for continuity of care and/or treatment by our office or another medical office. I acknowledge that I have received, read, and understand the Financial Policy and Release of Information which has been provided to me.

Health Insurance Portability and Accountability Act (HIPAA): I understand I have certain rights regarding the privacy of my protected health information. I acknowledge that I have received and have access to a copy of the Notice of Privacy Practices. I understand the practice has the right to change its Notice of Privacy Practices and Financial Policy and Release of Information and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices or Financial Policy and Release of Information. I may also contact the practice at any time with any questions I may have or if I have a concern regarding my protected health information. I authorize a copy of this authorization may be used in place of the original. I understand it is the policy of this office to remind patients of their appointments. This may be done by telephone or e-mail.

My signature below represents the above information is accurate to the best of my knowledge. I acknowledge I have obtained, understand, have access to and agree to abide by all the practices policies. I understand that this consent shall remain in force from this time forward.

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.

Updated 5/1/2017

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