Practice Consent Form

Contact Information

Last Name

First Name

M. I

Date of Birth

If Minor: Parent/ Legal Guardian Name(s)

Address if different

Mailing Address

Street Address

City

State

Zip

Primary Phone

Secondary Phone

Email address

Primary Care Physician

EMERGENCY

Emergency Contact Name

Emergency Contact Phone

Insurance

1st Insurance

Member ID #

2nd Insurance

Member ID #

Consent to speak/share your PHI with a relative/friend

PHI is your protected health information such as your Medical Information, Biopsy results, Plan of Care, or to answer billing/insurance questions.

Name:

Relationship

Phone Number

Consent To Leave Messages:

Do you authorize detailed messages to be left/sent via text, email, voice message or answering machine with medical information such as lab/biopsy results, prescription information, or to answer a billing/insurance question? NOTE: ALL appointments will be confirmed via phone, email, and text unless you request otherwise.

YES I DO

NO I DO NOT

Consent 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. Tocci, or Bri Schreiner, PA-C or at Cape Cod Dermatology, LLC is paid directly to Cape Cod Dermatology, LLC.

Consent To Release 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

Email address

Notice of Practice Policy

Please review our Practice Policy here before you sign this form

I hereby agree and acknowledge:

Financial Agreement: Patient or guarantor is financially responsible for all non-covered services, co-pays and deductibles.
Appointment and Cancellation Policy: Late arrivals may be rescheduled, missed appointments or appointments cancelled within 24 hours may be charged. Repeated missed appointments may result in dismissal from the practice.
Independent contractor: Dr. Elizabeth Tocci is directly employed and insured by Cape Cod Healthcare.
Patient Portal: An optional patient portal is available for use as a courtesy in partnership with Modernizing Medicine. Use of the patient portal is entirely voluntary and will not impact the quality of care received.
Patient Portal Safety: Patient portal is NOT for emergencies. Portal must be accessed on a secure network and password must be protected.
Privacy Policy: Cape Cod Dermatology, LLC will use and share my personal health information as outlined in the Notice of Privacy Practices printed on the Practice Policy.
Additional Rights regarding my protected health information are found on the Practice Policy.

I have read and agree to the Practice Policy

Signature

Date

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Notes

Your information will be encrypted and forwarded to office@capecodderm.net.

Your information will be encrypted.