Patient Information Form

Patient's Personal Information

Today's Date

Last Name

First Name

Middle Initial

Birthdate

Address

City

State

Zip

Age

Home Phone

Cell Phone

Work Phone

Other

SS #

Occupation

Employer

Employer Address

City

State

Zip

Nearest relative not residing with you:

Name

Phone #

Referred By

City

Phone #

Family Physician

City

Phone #

For Dependents Only - Parent Information

Parent/Guardian

Address

City

State

Zip

Home #

Work #

Other #

Date of Birth

Employer

SS# or Drivers License #

Parent / Guardian

Add Additional Parent/Guardian

Payment Information

Primary Insurance name

Name of insured

Insured’s Date of Birth

Insured’s ID # & Group #

Secondary Insurance name

Name of insured

Insured’s Date of Birth

Insured’s ID # & Group #

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

I do not have insurance but this is how I will pay in full for my appointment:

Person Financially Responsible

If not provided above, SS# or Driver's License #

Date of Birth

Address

City

State

Zip

Home #

Other #

Employer

Work #

Patient Relationship to responsible party

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.

Patient (Parent if Minor) Signature

Printed Name

Date

Email For Patient Portal Free Access

Your information will be encrypted.