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    Patient Information Sheet

    Uploaded by

    dgina8800
    This document is a patient information sheet collecting personal and insurance details for a new patient. It requests the patient's name, address, phone numbers, date of birth, employer, social security number, marital status, emergency contact, preferred pharmacy, and insurance information including primary and secondary carriers. It notes the patient is responsible for payment of charges not covered by insurance including co-pays and deductibles. The patient's signature is required to authorize the release of medical information to their insurance and to acknowledge financial responsibility.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Patient Information Sheet

    Uploaded by

    dgina8800
    48 views1 page
    This document is a patient information sheet collecting personal and insurance details for a new patient. It requests the patient's name, address, phone numbers, date of birth, employer, social security number, marital status, emergency contact, preferred pharmacy, and insurance information including primary and secondary carriers. It notes the patient is responsible for payment of charges not covered by insurance including co-pays and deductibles. The patient's signature is required to authorize the release of medical information to their insurance and to acknowledge financial responsibility.

    Original Description:

    healthcare

    Copyright

    © Attribution Non-Commercial (BY-NC)

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    This document is a patient information sheet collecting personal and insurance details for a new patient. It requests the patient's name, address, phone numbers, date of birth, employer, social security number, marital status, emergency contact, preferred pharmacy, and insurance information including primary and secondary carriers. It notes the patient is responsible for payment of charges not covered by insurance including co-pays and deductibles. The patient's signature is required to authorize the release of medical information to their insurance and to acknowledge financial responsibility.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    48 views1 page

    Patient Information Sheet

    Uploaded by

    dgina8800
    This document is a patient information sheet collecting personal and insurance details for a new patient. It requests the patient's name, address, phone numbers, date of birth, employer, social security number, marital status, emergency contact, preferred pharmacy, and insurance information including primary and secondary carriers. It notes the patient is responsible for payment of charges not covered by insurance including co-pays and deductibles. The patient's signature is required to authorize the release of medical information to their insurance and to acknowledge financial responsibility.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    .

    Patient Information Sheet


    (Please use black ink)

    Todays Date:________________

    Who referred you?________________________________

    Patients Name:_____________________________________________________________________________
    (Last)

    (First)

    (Middle)

    Jr. / Sr.

    Patients Mailing Address:____________________________________________________________________


    (Street)

    (Apt.)

    (City, State)

    (Zip Code)

    Patients Home Phone #:___________________________

    Patients Cell Phone #:______________________

    Patients Employer:_______________________________

    Patients Work Phone #:_____________________

    Patients Social Security #: ________________________


    Patient Date of Birth: _________________________

    Marital Status: M

    Age:_____________

    (check one)

    Sex: Male Female

    Guarantor (responsible for minors):___________________________ Relationship to patient:_______________


    Primary Insurance Company:___________________________
    Primary Policy Holder:_________________________________
    Primary Policy Holders Date of Birth:_________________

    Relationship to patient:_________________________

    Primary Policy Holders SS#:________________________

    Secondary Insurance Company:_________________________


    Secondary Policy Holder:_______________________________
    Secondary Policy Holders Date of Birth:________________

    Relationship to patient:_________________________

    Secondary Policy Holders SS#:_____________________

    If biopsy/lab testing is necessary, may we leave results on your answering machine? Yes No
    If biopsy/lab testing is necessary, may we leave results with another member of your household? Yes No
    If yes, with whom and what is their relationship to you?_____________________________________________
    Preferred Pharmacy and Location:________________________________________ Phone #:______________________
    In case of Emergency, whom should we contact (not living with you)? _______________________________________
    Relationship to Patient:_______________________
    Phone #:__________________________(Home)

    and

    Phone #:________________________(Work Cell)

    Payment is expected at the time of service for charges not covered by your insurance including office visit co-pays and
    deductibles. Amarillo Dermatology is not responsible for out-of-network denials or reduced benefit payments. It is the
    patients responsibility to verify network benefits. Your signature below indicates that you understand and accept
    responsibility for the charges not covered by your insurance and authorizes this office to release medical information
    necessary to process your insurance claim.
    You authorize payment of medical benefits to AMARILLO
    DERMATOLOGY when a claim is filed on your behalf. The patient is responsible for lab work and pathology billed by
    the pathologists that are independent from our office. Amarillo Dermatology charges $25 for missed appointments and
    appointments cancelled with less than 24 hours notice.

    __________________________________
    Patient (or Responsible Party) Signature

    _______________
    Date

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