Patient information Form

PATIENT INFORMATION FORM

Name:

Marital Status:

Single Married Divorced Widowed

Driver’s License No.:

State:

Social Security No:

Date of Birth:

Birth sex:

Male Female

In case of an emergency, who should be notified?

Name:

Relationship:

Phone:

Primary Phone:

Home Cell

Secondary Phone:

Home Cell

Is it ok to leave a detailed message?

Yes No

Would you like email notifications?

Yes No

Email:

Primary Care Physician:

Patient Address:

City:

State:

ZIP:

INSURANCE INFORMATION

(Please present current insurance cards at time of check in)

Person responsible for account?

Relationship to patient

Billing Address:

Same as Patient: Other

If other, specify:

Primary Insurance:

Subscriber’s Name:

Subscriber’s Date of Birth

Relationship to Patient:

Secondary Insurance:

Subscriber’s Name:

Subscriber’s Date of Birth

Relationship to Patient:

AUTHORIZATION TO RELEASE INFORMATION

I authorize information about my health care, including appointments, test results, or other messages to be left on my voicemail, in the event that I am not available.

Yes, send message via text (standard rates may apply)

I authorize Northwestern Michigan Dermatology, PC to discuss information relevant to my care with:

Parent

Spouse

Child/Children

Friend/Other

I do not authoirize release to anyone

Please list names:

A copy of Northwestern Michigan Dermatology, PC’s updated Notice of Privacy Practices is available for inspection at the reception desk at all times and on its web site. Additional copies of the notice can be obtained at no charge, upon request. By my signature below, I certify that I have read and understand the information disclosed in the notice. I also understand that changes to this notice can be made at any time, and that it is the patient’s responsibility to remain current on those changes.

OFFICE POLICIES

A copy of Northwestern Michigan Dermatology, PC’s updated Office Policies will be available for inspection at the reception desk at all times. Additional copies of the notice can be obtained at no charge, upon request. By my signature below, I certify that I have read and understand the information disclosed in the Office Policy notice. I also understand that changes to this notice can be made at any time, and that it is the patient’s responsibility to remain current on those changes.

My signature below authorizes Northwestern Michigan Dermatology, PC to release my medical information to process my insurance claims. I also authorize payment of medical benefits to Northwestern Michigan Dermatology, PC. I understand I am financially responsible for any amount not covered by my insurance contract.

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

SIGNATURE:

(Patient or Parent/Guardian if patient is a minor)

TODAY’S DATE:

Your information will be encrypted.