Patient InformationLast Name(Required) First Name(Required) Address(Required) City(Required) State(Required) Zip(Required) Date of Birth(Required) Gender(Required) Male Female Marital Status(Required)SingleMarriedDivorcedWidowedSeparatedRaceWhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderDecline to AnswerEthnicityPlease SelectHispanic or LatinoNot Hispanic or LatinoDecline to AnswerEmail(Required) Home PhoneCell PhoneBest Number to Call Home Phone Cell Phone Emergency Contact(Required) Relationship to Patient(Required) Emergency Contact Phone(Required) Primary Care Physician (PCP)Primary Care Physician(Required) Primary Care Phone(Required)Primary Care Address(Required) Pharmacy InformationPharmacy Name(Required) Pharmacy Phone(Required)Pharmacy Address(Required) Insurance InformationSubscriber Patient Relation to Subscriber Insurance Carrier Name(Required) Policy Number(Required) Subscriber Date of Birth(Required) Relationship to Patient Secondary Insurance Add Secondary Insurance Secondary Insurance Name Secondary Insurance Policy Number Secondary Insurance Subscriber Secondary Subscriber Relationship to Patient Perscription CoveragePrescription Cover Insurance Name Prescription Coverage Policy Number Bin Number PCN Number Group Number Please Review and Sign Responsible Party (person responsible for payment)Responsible Party(Required) Patient Other than Patient Reponsible Party Name First Last Reponsible Party Address Street Address Address Line 2 City State Zip Code Reponsible Party Date of Birth Reponsible Party Relationship to Patient Is Current Skin Condition Work Related(Required) Yes No I request payment of authorized Medicare or Insurance benefits on my behalf for any services furnished to me by Dermatology Services, Inc (DSI). I authorize any holder of medical or other information about me to be released to Medicare/Insurance and their agents any information needed to determine these benefits or benefits for related services. I certify that the information on this sheet is correct. I understand that even though I have some type of insurance coverage, I am responsible for payment of services. I authorize DSI to obtain my medication history from the pharmacy. I authorize DSI to exchange my personal health information with other health care providers using the MA e-highway and/or Modernizing Medicine secure communication system. I also authorize DSI to send text messages, and I understand that I can opt out of text messages at any time. I also authorize the physicians, nurse practitioners, physician assistants and staff at DSI to perform diagnostic tests and procedures and to undertake such treatment as deemed necessary or advisable in the care of myself or the above-named person. I consent to such procedures as have been explained to me by the provider and which meet my approval. PLEASE NOTE: It is the policy of this office that the adult presenting the child for treatment is responsible for payment of the patient portion of the bill at the time of service.Signer's Name(Required) First Last Date MM slash DD slash YYYY Relationship to Patient(Required) Self Parent Guardian
