Cape Cod Dermatology, LLC - Practice Consent Form

Cape Cod Dermatology , LLC
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

Practice Consents

Privacy Practices

Please review our Notice of Privacy Practices here before you sign this form.

I acknowledge that I have reviewed Cape Cod Dermatology, LLC's Notice of Privacy Practices dated 7/20/2023.

Signature

Date

Practice Policy Statement

Please review our Practice Policy Statement here before you sign this form.

I acknowledge that I have reviewed Cape Cod Dermatology, LLCs Practice Policy Statement dated 7/20/2023 outlining practice policies and my responsibilities relating to scheduling, cancelling, and keeping timely appointments. I understand that appointments will be confirmed via phone, email and/or text unless I have requested otherwise. I understand Dr. Tocciis an independent contractor 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 agree to follow the policies of this office.

Signature

Date

Notes

Your information will be encrypted.

Cape Cod Dermatology, LLC - Practice Consent Form

Cape Cod Dermatology , LLCContact Information

Insurance

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

Consent To Leave Messages:

Practice Consents

Privacy Practices

Practice Policy Statement

Cape Cod Dermatology , LLC
Contact Information