REGISTRATION INFORMATION

Date

Patient Last Name

Patient First Name

Middle initial

Street Address:

City:

State:

Zip Code:

Sex:

M F

Age:

Date of Birth

Home Phone

Social Security:

Occupation:

Work Phone

Cell Phone

Spouse/Responsible party (If Minor):

Relationship:

Mother Father

Address:

City:

State:

Zip Code:

Date of Birth

Social Security:

Name of Primary Insurance:

Identification #:

Group #:

Card Holder:

Date of Birth

Emergency Contact Person:

Phone #:

Purpose of Visit:

Referring/Primary Care Physician:

ASSIGNMENT OF INSURANCE BENEFITS

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered; without obtaining my signature on each and every claim to be submitted for myself and/ or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim.

Name of Insured

hereby authorized

Name of Insurance Company

to pay and hereby assign directly to Dermatology & Gastroenterology Associates all benefits, if any, otherwise payable to me for his/her services as described on the attached forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid to Dermatology & Gastroenterology Associates will be credited to my account, in accordance with the above said assignment.

Authorized Signature of Subscriber

Date

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