Patient's Name

E-Mail Address

Age

Sex

Race

Social Security #

Birthday (mm/dd/yyyy)

Marital Status

Mailing Address

City

State

Zip Code

Home Phone #

Work Phone #

Cell Phone #

Are you employed?

Are you allergic to any prescription medications?

Are you currently taking prescription medications?

Reason for visit

Were you referred by a physician?

Emergency contact

Phone #

Are there individuals you authorize the release of your medical information to?

Primary Insurance Information

Insurance Name

Insured Name

Insured Birthdate

ID#

Group / Policy #

SS # of Insured

Do you have secondary insurance?

Are you the carrier for the insurance?

Are you married?

Do you have a living will or durable power of attorney?

I agree to and authorize medical treatment as deemed necessary by Dermatology Clinic of Jackson I hereby authorize Dermatology Clinic of Jackson to furnish information concerning my treatment to insurance companies as deemed necessary, I hereby irrevocably assign to Dermatology Clinic of Jackson all insurance benefits payable to me by my insurance company, not to exceed the charges shown. I understand that I am financially responsible for any amounts that are not covered by my insurance company and this authorization. Dermatology Clinic of Jackson cannot accept responsibility for collecting insurance claims or for negotiating a settlement on a disputed claim. I understand that I am responsible for my account. The undersigned further agrees that in the event his/her account is turned over to an attorney, the undersigned shall be responsible for all costs of collection, including out of pocket expenses, court costs, and attorney fees. I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dermatology Clinic of Jackson for any services furnished me by that clinic. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

I agree.

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I acknowledge that I have read and understood the Notice of Privacy Practices.

Patient/Personal Representative Name:

Patient/Personal Representative Email Address:

If Personal Representative, please describe relationship to patient:

Submit