WELCOME

PATIENT INFORMATION

Patient Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Sex

Male Female

Date of Birth

Marital Status

Married Single Divorced Widowed

Driver's License #

Social Security

Employer

Status

Full Time Part Time Retired Disability Not Employed

Is patient a Student?

(Circle correct answer)

Full Time Part Time

Referring Physician

INSURED'S INFORMATION

Insured's Name

Relationship to patient:

Address

City

State

Zip Code

Date of Birth

Social Security

Sex

Male Female

Employer

SECONDARY INSURED INFORMATION

Insured's Name

Relationship to patient:

Address

City

State

Zip Code

Date of Birth

Social Security

Sex

Male Female

Employer

EMERGENCY CONTACT INFORMATION

In the event of an emergency, is there a friend, relative or neighbor we may contact?

Name

Home Phone

Relationship to patient

INSURANCE INFORMATION Our Receptionist will copy your insurance cards

Where and when is the best time to reach you?

If you have an answering machine: May we leave your or your dependent's normal test result on machine?

Yes No

I give my consent for

to have access to all of my financial and medical records.

I hereby authorize Applegarth Dermatology, P.C. and/or designate to provide medical treatment to me. I authorize Applegarth Dermatology, P.C. and/or designate to release information pertaining to my Treatment for insurance purposes and/or to receive payments otherwise payable to me for services rendered.

I understand that I am financially responsible for any and all services rendered by Applegarth Dermatology, P.C. Applegarth Dermatology bills insurance as a courtesy to our patients. I also understand that I am to furnish all necessary information such as policy number and completed insurance forms for any and all services payable by my insurance company so that my insurance may be properly filed.

I agree that in the event this account is turned over to our collection agency or our attorney for collection proceedings, I will pay all reasonable attorney and/or collection agency fees, court costs, and that all sums shall be without relief for valuation and appraisement laws.

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.

PRINTED NAME OF RESPONSIBLE PARTY

SIGNATURE OF RESPONSIBLE PARTY

Date

SIGNATURE OF WITNESS

Date

MEDICARE AUTHORIZATION

I request that payment of authorized Medicare benefits be made to Applegarth Dermatology, PC for any physicians services. I authorize any holder of medical or other information about me be released to the Health Care Financing Administration, its agents, any information needed to determine the benefits for related services.

SIGNATURE OF MEDICARE BENEFICIARY

Date

MEDIGAP AUTHORIZATION (SECONDARY INSURANCE TO MEDICARE)

I request that payment of authorized Medigap benefits be made payable to me or on my behalf to Applegarth Dermatology, PC. I authorize any holder of medical or other information about me be released to my Medigap insurance, its agents, any information needed to determine the benefits for related services.

SIGNATURE OF INSURED/PATIENT

Date

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

I acknowledge that I have reviewed and have been offered a copy of Applegarth Dermatology, P.C. Notice of Privacy Practices.

SIGNATURE OF PATIENT

Date

Your information will be encrypted.