Northest Dermatology: Patient Information

NORTHEAST DERMATOLOGY: PATIENT INFORMATION (Please Print)

Last Name: ______First: ______MI: ______Street Address: ______City: ______State: ______Zip Code: ______Date of Birth: ______/______/______Sex: _____ Male _____ Female SSN: ______Drivers License#: ______ST: ______Home Phone: ______Cell: ______Work: ______Marital Status: _____ Married _____ Single _____ Divorced _____ Widowed Employer Name: ______Employer Address: ______City: ______ST: ______Emergency Contact Name: ______Phone: ______Referring Doctor: ______Group/Location: ______May we leave personal information on your answering machine: _____ Yes _____ No May we e-mail medical information to you? _____ Yes _____ No E-Mail address: ______Responsible Party Information: Name: ______Address: ______Date of Birth: ______Social Security Number: ______If patient is a child, check your relationship: _____Mom _____ Dad _____ Grandparent _____ Other (Please Specify: ______) Do you give permission to discuss your medical information with family members? _____ No _____ Yes (If yes, list names: ______) How did you hear about Northeast Dermatology, P.A.? _____ Doctor Referral _____ Newspaper _____ Yellow Pages _____Sign _____ Billboard ____ Other Who is responsible for your bill? _____ Self _____ Spouse _____Parent _____ Other

INSURANCE COVERAGE: REQUIRED: Insurance Company (Primary) ______Policy # ______REQUIRED: Name of Insured/Policy Owner: ______REQUIRED: Policy Holder’s Date of Birth: _____/_____/_____ SSN: ______

REQUIRED: Insurance Company (Secondary) ______Policy # ______REQUIRED: Name of Insured/Policy Owner: ______REQUIRED: Policy Holder’s Date of Birth: _____/_____/_____ SSN: ______

Please present Insurance Card and Photo ID to receptionist for copying.

I authorize the release of any medical or other information necessary to process my insurance claims. I also authorize payment of benefits to the party or physician who accepts assignment on the claim. I understand that the payment of co-pays, co-insurance, and deductibles is due at the time service is rendered.

Please sign: ______Date: ______