Patient Registration Form

Please fill out this patient form prior to your upcoming visit. Thank you for your assistance and we look forward to seeing you!

First Name Middle Initial Last Name Street Address City State Zip Mobile Number Home Number Email Address Last 4 numbers of Social Security Number Pharmacy Name Pharmacy Address Date of Birth

Gender Male Female

Marital Status Single Married Divorced Widowed

Preferred Language English Spanish Asian Other

Employer Name Primary Care Physician

Did you receive a referral from another Doctor? Yes No

If so, what is the Dr.'s name?

Responsible Party

Guarantor (Responsible Party) Self Spouse Parent Other

Guarantor First name Guarantor Last Name Guarantor Date of Birth Guarantor Social Security Number Guarantor Street Address Guarantor City, State, Zip

Insurance Information

Primary Insurance Provider ID# Group # If other than patient (Name) Relationship to Patient

Secondary Insurance

Name of Secondary Insurance Provider Effective Date ID # Group # If other than patient (Name) Relationship to Patient Phone Date of Birth Last 4 of Social Security Number

Who to notify in case of emergency (nearest relative or friend)?

First Name Last Name Relationship to Patient Phone

Financial Assignment & Agreement

We participate in a variety of insurance plans and will directly bill your insurance under these plans. Some companies will pay fixed allowances for certain procedures, and other pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance.
In order to control billing costs, we request that charges not covered by insurance for office visits and procedures be paid at the conclusion of each visit.
I request the payment of authorized Medicare, Medicaid or private insurance benefits be made either to me or on my behalf to Advanced Dermatology Care, APMC for any services furnished by the provider. I authorize any holder of medical information about me to release the center's for Medicare and Medicaid services or my private insurance carrier and its agents any information needed to determine these benefits payable.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.

First name, middle initial, last name Date

Your Medical History

Reason for your visit

Are you allergic to any medication? Yes No

If yes, please list

Have you ever had a reaction to lidocaine or betadine? Yes No

List all medications you are currently taking (including prescriptions, over-the-counter meds, vitamins, and herbals)

Do you now, or have you ever had diseases or conditions of: (yes or no)

Medical Information Release Form (HIPPA)

Full Name (First and last)

Date: Thursday, 16 May 2024 (EDT)

Name:

Type your name to sign this document:

Typing name is equivalent to a handwritten signature

Scan this QR code with your phone:

Date of Birth

Release Information

I authorize the release of information including the diagnosis, records, examination rendered to me, and claims information.

This information may be released to: Spouse Children Other Information is not to be released to anyone

This release of information will remain in effect until terminated by me in writing.

Messages

Please call: My home My work My cell number

If unable to reach me: You may leave a detailed message Please leave a message asking me to return your call Other

The best time of day to reach me: Day and between (time)

Can lab results be left on your voicemail or answering machine? Yes No

First name, last name Date

Cosmetic Inquiry:

How did you hear about our office?

Patient Authorization

I consent to treatment, including biopsies, necessary for the care of the below named patient. I understand that I will receive a separate bill from Dr. T. Nicotri (a skin pathologist from Delta Pathology) for each skin specimen processed. (By law, Dr. Gremillion is required to send skin specimens to a pahtologist for Biopsies and surgeries.)

I authorize the release of all medical records to the referring and family physicians. I allow fax transmittal of my medical records, if necessary.

I acknowledge full financial responsibility for services rendered by Advanced Dermatology Care, Dr. Loretta Gremillion. I understand I have 30 days after insurance pays to pay in full. I also understand that if surgery is needed, I am required to pay the patient portion upon completion of the surgery. (This DOES NOT APPLY to Medicare or any Medicare related insurance plan).

I have read and fully understand the above consent for treatment, biopsies, financial responsibility, release of medical information, and insurance authorization.

Date Signature (First name, Last name)

Patient Consent and Acknowledgement of Receipt of Privacy

I understand that as part of the provision of healthcare services, Advanced Dermatology Care, creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care of treatment.

I have been offered a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing the consent. I understand that the organization reserves the right to change their Notice and practices. I understand that I have the right to object to the use of my health information for directory purposes, I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.

By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment and health care operations. I have the right to revoke this consent, in writing except where disclosures have already been made in reliance of my prior consent.

This consent is given freely with the understanding that:

Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations without my prior written authorization, except as otherwise provided by law.
A photocopy or fax of this consent is as valid as this original.

I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purpose of treatment, payment or health care operations be restricted. I also understand that the Practice and I must agree to any restriction in writing that I request on the use and disclosure of my Protected Health Information and agree to terminate any restrictions in writing on the use and disclosure of my Protected Health Information which may have been previously agreed upon.

Patients first and last name