Doherty Dermatology
DOHERTY DERMATOLOGY
PATIENT REGISTRATION
Patient Information
Appointment Date: ______Time: ______
Last name: ______First name: ______Middle Initial: ______
Date of birth: ______Sex: M F
Address: ______Apt/Ste #: ______
Zip Code: ______City: ______State: ______
Preferred phone#: ______Alt phone#: ______
Employer: ______Work phone#: ______
Employment Status: full-time part-time self-employed retired unemployed
Marital Status: Single Married Divorced Legally Separated Widowed
Email address: ______Social Security #: ______
- Ethnicity: REQUIRED ( ) Hispanic or Latino ( ) Not Hispanic or Latino ( ) Unknown
- Preferred Language: REQUIRED ______
- Race: REQUIRED( ) American Indian or Alaska Native ( ) Asian ( ) Black or African American
( ) Native Hawaiian or Other Pacific Islander ( ) White ( ) Other Race
**Federal Health Requirement
I consent to allow secure access to my Electronic Health Record to the following people: (Does not include medical professionals). Forms of communication may include phone access, delivering lab results verbally or in person, discussing my medical condition, picking up copies of electronic medical record, and/or my appointment information:
Name, relationship, and phone:
______
______
______
SIGNATURE OF PATIENT or legal guardian (must be 18 yrs. or older to sign)Date
Responsible Party Information (if patient is under the age of 18)
Last name: ______First: ______Middle Initial: ______DOB: ______
Address: ______Apt/Ste #: ______
Zip Code: ______City: ______State: ______
Preferred phone#: ______Alt phone#: ______
Employer: ______Work phone#: ______
Employment Status: full-time part-time self-employed retired unemployed
Primary Insurance
Primary Insurance Company: ______
Subscriber’s name: ______ID number: ______
Group Name: ______Group #: ______
Patient Relationship to Subscriber: self spouse child other
Subscriber Date of Birth: _____ / _____ / ______Subscriber Social Security#: ______
Copay: ______Student Status: full-timepart-time
Secondary Insurance
Secondary Insurance Company: ______
Subscriber’s name: ______ID number: ______
Group Name: ______Group #: ______
Patient Relationship to Subscriber: self spouse child other
Subscriber Date of Birth: _____ / _____ / ______Subscriber Social Security#: ______
Copay: ______Student Status: full-timepart-time
Medicare Patients Only
Answer the questions below by placing a check in the appropriate column:
YesNo
( )( ) Do you or your spouse work in a company which has more than 20 employees and has coverage through the insurance at that job?
( )( ) Are you covered by a HMO/PPO which makes Medicare secondary?
( ) ( ) Is this illness covered by the VA (Veteran’s Administration)?
( )( ) Is this illness covered by the Federal Black Lung or End Stage Renal Disease Program?
( )( ) Is this illness due to an automobile accident?
( )( ) Is this illness due to an injury at work?
( )( ) are you receiving Medicaid?
This office is required to keep your signature on file authorizing us to file claims to Medicare for you and to release information to that payer if they require it for the proper consideration of a claim. Please read and sign the following statement:
I authorize any holder of medical or other information about me to release to the Social Security Administration or it intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.
______
Signature as it appears on Medicare cardDate
Please complete the front and back side of each page