Add Secondary Insurance
If yes, please provide their names and phone numbers below.
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My signature below indicates that I have received and/or reviewed a copy of Lakeside Dermatology’s Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices).
DISCLAIMER: By signing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Self-Pay Patients - I understand that I am required to pay 100% of the total bill at the time of service.
Insured Patients - I understand that I will be responsible for paying my deductible, co-payment, co-insurance, and charges for any non-covered and/or cosmetic services.
Laboratory Services - I understand that if I have a skin biopsy and/or any other laboratory services performed, it will be sent to an outside laboratory to be tested and I may receive a bill from the laboratory (for example: Ameripath, IRL, Quest, LabCorp, etc.) and it is my responsibility to inform Lakeside Dermatology, LLC staff if my insurance requires a particular laboratory.
Cancellation Policy-I understand that if I fail to give 48 business hours’ notice to cancel or reschedule my appointment, that I will be required to pay a $150 Surgical Appointment or $50 Dermatologic Appointment fee.
Assignment and Release
I hereby authorize payment directly to Michael J. Rogers, MD and Lakeside Dermatology, LLC for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in Lakeside Dermatology to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
(This will be the pharmacy where all of your prescriptions will be sent)
Please list all current prescription and/or OTC medications
Add Another Medication
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