Face Sheet Aqua Medical Spa printable pdf download

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FACE SHEET/PATIENT INFORMATION

Name______________________________________________________ Date of Birth______________ Age______ Sex _________

Mailing Address_____________________________________________ City_____________________ State____ Zip ____________

Home Phone_____________________ Cell Phone ______________________ E-Mail Address:________________________________

Employer ______________________________________________ Employer Phone # _____________________________________

Social Security # _____________________________ Emergency Contact _______________________________________________

Primary Physician____________________________________ Referring Physician_________________________________________

*Primary Insurance _________________________________________ ID Number ________________________________________

Cardholder’s Name________________________________________ Cardholders SSN # ____________________________________

Relationship to Patient________________________________________________ Cardholder’s Date of Birth___________________

Cardholder’s Employer_________________________________________________________________________________________

*Secondary Insurance_______________________________________ ID Number_________________________________________

Cardholder’s Name ________________________________________ Cardholder’s SSN # ___________________________________

Relationship to Patient ________________________________________________ Cardholder’s Date of Birth __________________

Cardholder’s Employer_________________________________________________________________________________________

I hereby authorize my insurance benefits including Medicare to be paid directly to Aqua Medical Spa. This assignment will remain in effect until revoked by me in

writing I understand that I am financially responsible for all charges whether or not paid by said insurance. I herby authorize said assigned to release all information

necessary to secure that payment. In the event that this account is assigned to collections, I agree to pay all cost of collection including reasonable attorney fees. It

is the policy of Aqua Medical Spa to provide services to all persons without regard to race, color, national origin, religion, sex, age or disability.

If you believe you have been denied a benefit of some service because of your race, color, national origin, religion, sex, age or disability, you may file a complaint of

discrimination with our office, either verbally or in writing.

RECEIPT OF NOTICE OF PRIVACY PRACTICES:

My signature below indicates that I have received and/or reviewed a copy of my physician’s Notice of Uses and Disclosures of Protected Medical Information

(Notice of Privacy Practices).

Patient or Responsible Party Signature___________________________________ Date ____/____/_________

PAYMENT POLICY:

HMO, PPO, or other managed care patients: You will be responsible for paying your annual deductible, co-payment and charges for any non-covered and

cosmetic services at the time of service.

COMMERCIAL PATIENTS WHO ARE NOT IN-NETWORK: Patients who are covered by private, commercial plans in which our physicians are not providers will be

required to pay the total bill at the time of service.

COMMERCIAL PATIENTS WHO ARE IN-NETWORK: Patients who are covered by private, commercial plans in which our physicians are providers will be required to

pay the balance of the bill before or on the date of your next visit if we have not been paid from your insurance company within 60 days we will provide you with

the information necessary to contact your insurance company upon request.

Patient or Responsible Party Signature ___________________________________ Date ____/____/_________

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