Cape Cod Dermatology, LLC - New Patient Intake

Contact Information

Last Name

First Name

M.I

Date of Birth

Mailing Address

Street Address

(if different)

City

State

Zip

Home Phone

Cell Phone

Work Phone

Email Address

Emergency Contact Name

Emergency Contact Home Phone

Emergency Contact Cell Phone

Please note: Appointments will be confirmed via phone, email and/or text unless you have requested otherwise.

If Minor: Parent/Legal Guardian Names

Responsible Party (if not self)

Primary Care Physician

If none please type 'none'

What is your main reason for today’s visit?

Insurance

1st Insurance

Member ID #

Subscriber Name

Subscriber Date of Birth

2nd Insurance

Member ID #

Subscriber Name

Subscriber Date of Birth

3rd Insurance

Member ID #

Subscriber Name

Subscriber Date of Birth

Messages

I authorize messages via text, email, voice message or answering machine with medical information such as lab/biopsy results, prescription information, or billing/insurance.

YES I DO

NO I DO NOT

Communication Permission

If desired, please list below a Relative or Friend that you would give permission to inform or discuss your Medical Information, Biopsy results, Plan of Care, or billing/insurance.

Name:

Relationship

Phone Number

Practice Policy Agreement

Before you sign this form, please read our Practice Policy Statement please review it here before you complete this form.

I have read and agree to the Practice Policy Statement

Patient Agreement

By signing below, I agree that I have familiarized myself with the policies of this office and all of my questions have been answered. I acknowledge that I have received a copy of Cape Cod Dermatology, LLCs Practice Policy Statement dated 7/1/2020 outlining practice policies, and my responsibilities relating to scheduling, canceling, and keeping timely appointments. I understand that appointments will be confirmed via phone, email, and/or text unless I have requested otherwise. I understand that Dr. Girouard and Dr.Tocci are independent contractors practicing on-site. I understand and agree that I am financially responsible for all rejected or non-covered services, and all co-pays and deductibles. I agree to access the patient portal in a secure manner. I know my rights regarding my protected health information.

Request for Payment

By signing below, I request payment of all eligible and authorized insurance benefits including but not limited to Medicare, Medicaid, Supplemental, Medigap, Commercial, and Private for me or on my behalf for any services provided by Dr. Fiske, Dr. Girouard, Dr. Tocci, or Bri Schreiner, PA-C or at Cape Cod Dermatology, LLC be paid directly to Cape Cod Dermatology, LLC.

Release of Information

By signing below, I authorize the release of any medical or other information necessary to Medicare, Medicaid, Supplemental, Medigap, Commercial, and Private Insurance and its agents any information needed to determine these benefits or benefits for related services.

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 Name / Signature

Date

Notes

Your information will be encrypted.

Cape Cod Dermatology, LLC - New Patient Intake - Portal

Contact Information

Please note: Appointments will be confirmed via phone, email and/or text unless you have requested otherwise.

Insurance

Messages

Communication Permission

Practice Policy Agreement