Please print and complete this form prior to your visit.


INFORMATION REGARDING THE PATIENT (PLEASE PRINT)

DATE


LAST NAME: 

FIRST NAME: 
M.I.: 

STREET ADDRESS: 

CITY: 

STATE: 

ZIP: 

MAILING ADDRESS: 

HOME PHONE #: 

SEX: 

DRIVER'S LIC. #: 

DATE OF BIRTH: 

AGE: 

SOCIAL SECURITY NUMBER: 

PATIENT'S EMPLOYER (no abbreviations): 

OCCUPATION: 

EMPLOYER'S ADDRESS: 

WORK PHONE #: 

SPOUSE'S NAME: 

REFERRED TO US BY: 

RESPONSIBLE PARTY INFORMATION  (COMPLETE ONLY IF OTHER THAN PATIENT)


RESPONSIBLE PARTY (as appears on ins. Card): 

SOCIAL SECURITY #: 

RELATIONSHIP TO PATIENT: 

DRIVER'S LIC. #: 

ADDRESS: 

CITY: 

STATE: 

ZIP: 

PHONE #: 

DATE OF BIRTH: 

OCCUPATION: 

EMPLOYER (no abbreviation): 

BUSINESS PHONE: 

EMPLOYER ADDRESS: 

Participating PPO/HMO/Medicare information - Please present your insurance card to the receptionist: If you are on one of the health care plans in which we participate, you must give us complete information including an insurance card copy, referral number/letter (if applicable) so that your coverage can be verified. If this information is not received prior to or on the day of your visit, your visit will be fee-for-service. Non-covered/cosmetic/medically unnecessary procedures are also fee-for-service. Your copayment and deductible is required at the time of service in order to keep costs down. We will provide you information necessary to file your claim for reimbursement.


INSURANCE INFORMATION (PLEASE ALLOW US TO MAKE A COPY OF YOUR INSURANCE CARD)


PRIMARY INSURANCE COMPANY: 

INSURANCE COMPANY PHONE #: 

INSURANCE CO. ADDRESS
POLICY #: 

GROUP #: 

NAME OF INSURED (as appears on ins. Card): 

INSURED'S DATE OF BIRTH: 

INSURED'S SOCIAL SECURITY #: 

RELATIONSHIP TO PATIENT: 

EMPLOYER (no abbreviations): 

I have read all the information of this sheet and have completed the above answers to the best of my knowledge. I will notify you of any changes in my health status or the above information. I hereby authorize Dermatology Center of Dallas to furnish information to insurance carriers concerning my medical status. I understand that I am responsible for any amount not covered by my insurance.


SIGNATURE: 

DATE: 


PATIENT INFORMATION FORM 8/7/98