New Patient Information Form

Dermatology at MidTowne

Please correct the errors described below.

Dear New Patient,

Thank you for choosing Dermatology at MidTowne!

To prepare for your upcoming appointment, please fill out the form below at least 1 week prior to your appointment.

Directions to our office may be found on our website at

Please bring your driver's license (or government-issued ID) and your insurance card(s) to your appointment. A minor patient must be accompanied by a parent or legal guardian.

Note that any identifiable and applicable co-pays will be collected at the time of your visit.

You will receive a call to confirm the date and time of your appointment three business days prior to your scheduled visit. If you are unable to keep your appointment as scheduled, kindly notify our office at least 48 hours in advance. You will be charged a no-show fee if you cancel less than 24 hours prior to your appointment.

If you have any questions or concerns, please feel free to contact our office at (616) 248-8864.

We look forward to your visit!

Patient Information

Please complete this form in its entirety. Feel free to ask one of our staff members for assistance.

Insurance Information


Secondary Insurance (if applicable)

Dermatology at MidTowne, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex

Patient History

Medical History

Medications - Please list all present medications, including creams & supplements:

Skin Disease History

Social History

Review of Systems

Do you currently have or have you had in the past any of the following?

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

HIPAA Privacy Notice & Authorizations

HIPAA AUTHORIZATION: We must have your permission on file if you wish for us to be able to discuss your medical care and/or billing information with others. Please list the name(s) below of persons we are permitted to talk to and in what capacity. Please be sure to indicate at least one Emergency Contact. Thank you.

PRIVACY POLICY: The Notice of Privacy Practices is stated below of this form. (A Larger Font copy is available at the front desk.) Your signature indicates you have had an opportunity to review this policy and agree to comply with it.

FINANCIAL POLICY: Patients are expected to pay for any identifiable and applicable co-pays at the time of their appointment. Patients who are covered by private, commercial insurance plans that our physicians do not participate with are required to pay one hundred percent (100%) of the bill at the time of service. If they are covered by a plan with which we have a contract, applicable and determinable co-payments and deductibles may be collected at the time of service. Patients are responsible for paying one hundred percent (100%) of non-covered or cosmetic services. Payments for amounts billed to you are due within twenty (20) days of receiving a statement. Your signature indicates your willingness to comply with this policy.

INFORMATION RELEASE: I authorize the release of information to my primary care or referring physician, to consultants if needed, and as necessary to process insurance claims, insurance applications, and prescriptions. I authorize payment of medical benefits directly to the physician.

AUTHORIZATION FOR CONTACT: You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails. Using any e-mail address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

FOR MEDICARE PATIENTS ONLY: I request that payment of authorized Medicare benefits be made on my behalf to Dermatology at MidTowne, PC for any services furnished me by its providers. I authorize the release of information to the Centers for Medicare and Medicaid Services and its agents in order to determine benefits and payment of the claim. If "other health insurance" is indicated, I authorize releasing of the information to the insurer or agency shown. I permit a copy of this authorization to be used in place of the original. I understand I am responsible for co-insurance and deductible amounts as directed by my Medicare carrier. (Dermatology at MidTowne is a participating provider.)


By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Notice of Privacy Practices for Dermatology at Midtowne, PC


The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a Federal program that
requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your protected health information ("PHI") is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operation.

  • Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this is a primary care doctor referring you to a specialist doctor.
  • Payment means such activities as obtaining re imbursement for services, confirming coverage. billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery.
  • Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. An example of this would be new patient survey cards.
  • The practice may also be required or permitted to disclose your PHI for law enforcement and other legitimate reasons. In all situations, we shall do our best to assure its continued confidentiality to the extent possible.

We may also create and distribute de-identified health information by removing all reference to individually identifiable information.

We may contact you, by phone or in writing, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you. You do have the right to "opt out" with respect to receiving fund raising communications from us.

The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

  • Most uses and disclosure of psychotherapy notes;
  • Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
  • Disclosures that constitute a sale of PHI under HIPAA; and
  • Other uses and disclosures not described in this notice.

You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior authorization.

You may have the following rights with respect to your PHI:

  • The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of Protected Health Information by alternative means or at alternative locations.
  • The right to inspect and copy your PHI.
  • The right to amend your PHI.
  • The right to receive an accounting of disclosures of your PHI.
  • The right to obtain a paper copy of this notice from us upon request.
  • The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

If you have paid for services "out of pocket", in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.

We are required by law to maintain the privacy of your PHI and to provide you the notice of our legal duties and our privacy practice with respect to PHI.

This notice if effective as of 09/2013 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post a copy and you may request a written copy of the revised Notice of Privacy Practice from our office.

You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with the practice and with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

Feel free to contact the Practice Compliance Officer at (616) 248-8864 ext 201 for more information.

(Revised 10/2016) Dermatology at MidTowne, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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