Patient Registration

Please enter information EXACTLY as printed on your insurance card.

Account #

Patient #

SSN #

First Name

Middle

Last Name

Address

City

State

Zip

Age

Birthdate

Your Employer

Email address

If Student, Circle One

Full-Time Part-Time

Referral Source Or Referring Doctor

PERSON FINANCIALLY RESPONSIBLE FOR THE BILL (GUARANTOR)

First Name

Middle

Last Name

Street Address

City

State

Zip

Relationship to Guarantor

Birthdate

SSN #

Employer

Work Phone

Cell Phone

Home Phone

INSURANCE INFORMATION

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RELEASE OF INFORMATION

Your signature authorizes Center of Dermatology, P.C. to release such medical information necessary to process your insurance claims (if any). You herein authorize payment of medical benefits to Center of Dermatology, P.C. when an assigned claim is filed. You also certify that all of the information that you have provided to Center of Dermatology, P.C. is complete and accurate. A photocopy hereof shall be valid as the original.

PAST DUE INVOICES ARE SUBJECT TO A 1.33% PER MONTH INTEREST CHARGE

YOU MUST BE 19 YEARS OLD OR OLDER TO SIGN

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.

Signature

Date

Please Upload Insurance Cards And Photo I.D. So Copies May Be Made.

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Please upload a file

CONCERNING YOUR INSURANCE

We will file your insurance

When we are a provider for your insurance program or
When your account is paid at the time of service

In order to file your insurance, we must have the following information:

A photocopy of your insurance card. This should have the policy number, group number, insured’s name, and the address and telephone number of the insurance company
Insured’s birth date
Insured’s Social Security number
Insured’s place of employment

We cannot file an insurance claim without all of this information.

CONCERNING MEDICARE BENEFITS

This office accepts assignment for Medicare patients. This means that we will submit a claim for you and agree to accept Medicare’s fee schedule. You are responsible for the annual 100% deductible and 20% of the amount approved by Medicare. Medicare pays 80% of the approved amount. If you have any questions, you can reach the Medicare Beneficiary Line at 1-800-633-1113

CONCERNING YOUR MANAGED CARE INSURANCE

You must have a referral from your Primary Care Physician, if your insurance requires one.

Arrangements for the referral are your responsibility.

If you do not have a referral for your office visit or authorization for service, you are responsible for payment in full.

CONCERNING NON-COVERED SERVICES

Payment for services that are considered cosmetic and charges that are not eligible for payment by your insurance company are your responsibility

I agree to pay the copay, deductible, and coinsurance; whichever are applicable

I agree to pay the copay at the time of my appointment. I agree to pay a $5.00 billing charge if I fail to pay my copay within 7 days of the appointment.

I agree to be personally and fully responsible for payment if I fail to obtain a referral or authorization for service when required by my insurance plan

I agree to pay for all non-covered services

I agree to pay a $35.00 fee for any returned checks

I agree to pay a 1.33% per month late charge on past due invoices

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.

Signature

Date

PRIVACY PRACTICES ACKNOWLEDGEMENT

Name

Date of Birth

I Have Received The Notice Of Privacy Practices And I Have Been Provided An Opportunity To Review It.

Signature

Date

Your information will be encrypted.