ALTZ01 Patient Registration Form

Patient Registration

Patient Name *

First Name

Middle Name

Last Name

Preferred Name

Maiden Name (if applicable)

Date of Birth *

Date

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

The above number is my *

Cell phone number

Home phone number

Other phone number

Email

example@example.com

Patient Employer *

Sex

Male

Female

Age

Marital Status

Family Doctor *

Referred by

Preferred Pharmacy (Name)

Pharmacy Location

REASON FOR APPOINTMENT *

Current or former Dermatologists seen

Medication List

Drug Allergies *

Please list all medications you are currently taking, including prescription and over-the-counter. *

Do you have insurance? *

Yes

No

Primary Insurance

Insurance Company

Member ID

Subscriber Name

First Name

Last Name

Subscriber Date of Birth

Date

Subscriber Employer

Relationship to patient

Self

Parent

Spouse

Is your insurance plan through PA Medicaid, self pay or an employer?

Do you have secondary insurance?

Yes

No

Secondary Insurance

Insurance Company

Member ID

Subscriber Name

First Name

Last Name

Subscriber Date of Birth

Date

Subscriber Employer

Relationship to patient

Self

Parent

Spouse

PLEASE READ AND SIGN!!

*Our Team of providers includes: Dr. Anna Berning-dermatologist; Danielle Becker, PA-C- physician assistant; and Dr. Patrick McLucas-general practice licensed physician with a special interest in dermatology.

*Patients under the age of 18 must be accompanied by an adult

*It is our office policy that copays for office visits are due at the time of service, and I understand that I am responsible for any amount not covered by my insurance. Also, there will be a service charge of 1.5% per month on balances carried more than 30 days. Minimum finance charge of $3.00. After 3 no shows or cancel without 24 hour notice, I understand I may be discharged from the practice.

*l authorize Altoona Dermatology Associates to fax or email my medical records to my PCP upon request

STATEMENT TO PERMIT PAYMENT OF MEDICARE/COMMERCIAL INSURANCE BENEFITS TO ALTOONA DERMATOLOGY: I certify that the information given by me in applying for payment under title XVIII of the social security act is correct. I authorize my holder of medical or other information about me to release to the social security administration or it's intermediaries or carriers any information needed for this or a related medical claim. I request the payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physicians furnishing the service or authorize such physician or organization to submit a claim for payment. I request that payment under the medical insurance program be made to Altoona Dermatology Associates.

BY SIGNING BELOW I ACKNOWLEDGE I HAVE READ THE OFFICE POLICIES AND HAVE BEEN OFFERED A COPY OF THE PRIVACY POLICIES.

***I give permission to release information/pathology results to the following family members:

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Date