Patient Information Form

Please correct the errors described below.

Patient's Personal Information

Nearest relative not residing with you:

For Dependents Only - Parent Information

Parent / Guardian

Add Additional Parent/Guardian

Payment Information

Please provide receptionist with your current insurance card(s) and photo ID.

I understand that co-pays and/or deductibles are due at the time of service. There will be a $35 charge for returned checks. I have read the current GDMD collection procedures at the reception counter and agree to the terms. Authorization to release information: Protected health information may be disclosed or used for treatment, payment, or health care operations (TPO) including processing insurance and with other physicians (s) involved in my care. I have had the opportunity to review the “Notice of Privacy Practices” and may obtain a copy if I desire. I authorize my insurance company to pay Greater Des Moines Dermatology, P.C. directly for all surgical and/or medical benefits. I am financially responsible for ALL non-covered services. Medicare authorization: I understand this is a lifetime authorization. I authorize access to sure scripts database to provide prior medication history. Interest is charged on delinquent accounts. You will be provided access to the patient via the email you provide.

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.