Patient Registration Form (Fillable)

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Patient Registration
Today's date: ______/______/2016
Last Name ________________________________ First Name ___________________________ M.I._______
Your Social Security # ______________________ Male / Female Your Date of Birth _____/______/______
Mailing Address _______________________________ City, State _____________________ Zip __________
Home Phone ____________________
May we leave messages? Y
N Cell phone__________________
Work Phone_____________________
May we call you at work? Y N Employer Name______________
Marital Status M S D W Spouse's Name (if applicable) ______________Spouse’s Employer____________
Emergency Contact (outside of household): Name______________________ Relationship_______________
Contact’s Phone: (
)______________________________
Please list family members who are patients here ________________________________________________
Primary Care Physician’s Name _____________________________ Phone ___________________________
**List e-mail address for appointment reminders & online bill pay:_____________________________________
FOR MINOR-AGE PATIENTS (Complete if patient is under 18 years old)
Mother's Name _____________________________Work Phone ___________________________________
Father's Name ____________________ Work Phone _____________ Patient lives with _________________
Name of person bringing in patient ______________________________ Relationship _________________
Address _________________________________ City, State _____________________ Zip _____________
Social Security # ___________________Home Phone _________________ Work Phone ________________
Date of Birth ________________________ Employer ___________________________________________
FINANCIAL RESPONSIBILITY STATEMENT , CONSENT TO TREATMENT, HIPAA CONSENT,
RELEASE OF INFORMATION AUTHORIZATION AND CANCELLATION POLICY
I consent to the treatment necessary for the care of the above-named patient.
The “Spencer Dermatology's Notice of Privacy Practices” has been made available to me.
I authorize the release of my medical records to the referring and family physicians.
I authorize the release to my insurance companies those records necessary to determine payable benefits.
I authorize fax transmittal of my medical records to authorized parties.
I authorize and request that insurance payments be made directly to Spencer Dermatology Assoc., LLC.
I acknowledge full financial responsibility for services rendered, including deductibles and co-insurance.
I agree to pay fees for checks returned by the bank.
In the event that my account is referred to a collection agency, I agree to pay all collection costs including $50 office
collection fee, 35% collection agency fee for total account balance and reasonable attorney’s fees.
I understand that if I am unable to keep my appointment, I must cancel at least 24 hours in advance.
I acknowledge full financial responsibility for the $50 administrative fee charged due to my failure to keep or cancel
an appointment, and understand that these fees cannot be billed to my insurance company.
__________________________________________ Date__________/_________/2016
2017__________
Patient Signature
___________________________________________ Date__________/_________/2016
2018__________
Parent or Guardian Signature (if patient is a minor)
2019__________
**PLEASE COMPLETE OTHER SIDE**

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