Face Sheet Patient Information Template printable pdf download

FACE SHEET / PATIENT INFORMATION

_____

___

___________

________

_______

Primary Phone______________________ _______________________ Secondary Phone___________________________________________

E-mail Address_____________________________________________Social Security #

______________________________________

_______

________________________Employer Phone #____________________

: Name__________________________ Phone________________________Relationship _________________________

_______

_________

*Secondary Insurance _____________________________________________ID Number __________________________________________

Cardholder’s Name_______________________________________________________ Cardholders SSN #_____________________________

Relationship to Patient______________Cardholder’s Date of Birth_____________Cardholder’sEmployer______________________________

___ American Indian or Alaska Native

___ Asian

___ Native Hawaiian or Other Pacific Islander

___ Hispanic

RACE:

___ Black or African American

___ White

___ Unreported / Refused to Report

___ Other Race______________

___ Not-Hispanic or Latino

___ Unreported / Refused to Report

Ethnicity: ___ Hispanic or Latino

Primary Language: ___ Arabic

___ Chinese ___ English ___ French ___Korean ___ Spanish ___ Other _______________________

RELEASE OF MEDICAL INFORMATION

I, the undersigned as the patient or his/her representative, do hereby authorize Southeastern Dermatology Group, P.A., to release to my

insurance company(ies) or other appropriate agency(ies) that information which is necessary to validate this claim. Southeastern

Dermatology Group, P.A. is also hereby authorized to release to my physician(s), wither as an individual(s) or as a professional association,

who perform services for me, the patient, on a fee for service basis such information as is necessary for billing purposes. I hereby authorize

Southeastern Dermatology Group, P.A. to release any medical information to physicians other than original referring providers, who may

be involved in my or my child's health care treatment, when requested by these physicians. By signing this consent, information will be

given to requesting providers without further signed authorization. I hereby give permission to disclose, discuss and speak with personal

medical information about my treatment to the following individuals: Unless specifically listed below, we cannot speak to any individual

concerning your medical or financial information including, appointments, test results, prescriptions, school or work excuses, etc. This

includes your spouse, children, etc., we must have them listed by name.

Release information to (below):

Name:______________________________Phone:___________________Relationship:______________________

Restrict / DO NOT RELEASE ANY INFORMATION

Face Sheet Patient Information Template

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