REGISTRATION DERMATOLOGY CENTER OF NORTHWEST INDIANA PC Today’s Date
(Please Print) DRS M BRESSACK, M GRIEM & A GARLAPATI
(Please Complete Both Sides) H UPCHURCH, PA-C ______
70 West 94th Place, Crown Point, IN 46307
Telephone (219) 662-8822
PATIENT INFORMATION:
NAME______SS#______
(last) (first) (middle)
ADDRESS______HOME PHONE______
(street)
______CELL PHONE______
(city) (state) (zip code)
E-MAIL______DRIVERS LIC #______
BIRTHDATE______AGE______SEX: M F MARITAL STATUS: S M D W
OCCUPATION______WORK PHONE______
EMPLOYER NAME______EMPLOYER PHONE______
EMPLOYER ADDRESS______
(street)
______
(city) (state) (zip code)
RESPONSIBLE PARTY (GUARANTOR) INFORMATION (if different from patient):
NAME______SS______
(last)(first) (middle)
RELATIONSHIP TO PATIENT______CELL PHONE______
ADDRESS______HOME PHONE______
(street)
______WORK PHONE______
(city)(state (zip code)
EMPLOYER NAME______EMPLOYER TELEPHONE______
EMPLOYER ADDESS______
(street)(city)state) (zip code)
INSURANCE INFORMATION: (Please present insurance, Medicare or Medicaid cards to receptionist) CHECK IF NO INSURANCE
IF ON MEDICARE, #______IF ON MEDICAID, #______
PRIMARY INSURANCE NAME______
Ins Address______
______
Name of Insured ______
Insured’s ID#______
Group #______
Insured’s Date of Birth______
Insured’s Phone______
Employer Name______
Employer Address______
Employer Phone______
Relationship of patient to the insured______
SECONDARY INSURANCE NAME______
Ins Address______
______
Name of Insured ______
Insured’s ID#______
Group #______
Insured’s Date of Birth______
Insured’s Phone______
Employer Name______
Employer Address______
Employer Phone______
Relationship of patient to the insured______
IN CASE OF EMERGENCY CONTACT: ______TELEPHONE______
REFERRED BY______
RECEIPT OF NOTICE OF PRIVACY PRACTICES:I have had an opportunity to review the practice’s Notice of Privacy Practices.
X______
(signature of insured/responsible party)(date)
INSURANCE, MEDICARE & MEDICAID ASSIGNMENT AUTHORIZATION AND RELEASE: I assign directly to Dermatology Center of Northwest Indiana PC all medical benefits otherwise payable to me for services rendered, whether from Medicare, Medicaid, or my insurance company (including Medigap policies). I hereby authorize release of all information necessary to secure the payment of such benefits. I authorize any holder of medical information about me to release to Medicare, Medicaid, my insurance company or their agents any information needed to determine these benefits or the benefits payable for related services. I authorize the use of this signature on Medicare, Medicaid, and insurance submissions.
X______
(signature of insured/responsible party)(date)
FINANCIAL RESPONSIBILITY: I understand that I am financially responsible for all charges whether or not paid by insurance, including those deemed “not a covered benefit”, “not medically necessary”, and before or after date of eligibility. Any bills not paid by my insurance within 60 days of filing will be sent to me for payment or to follow up with my insurance. I agree to pay the full and entire amount of any and all bills for services rendered. I understand that accounts over 60 days old are considered delinquent. I agree to pay a statement fee of $5.00 fee per month on all unpaid balances after 60 days. I understand that a fee of 40% of the amount due will be added if my account is turned to a collection agency. I understand that I will be responsible for all legal fees if my account is turned to a lawyer for collection.
X______
(signature of insured/responsible party)(date)
A NOTE REGARDING “NOT MEDICALLY NECESSARY” AND “COSMETIC” PROCEDURES: As you may know, all health insurance contracts contain a clause limiting coverage to "medically necessary" services and procedures, excluding coverage for services and procedures that are considered "cosmetic". Over the past few years, more and more insurance companies have been considering many dermatologic services and procedures either "not medically necessary" or "cosmetic", and have been denying coverage and payment for these.
Among the services many insurance companies have begun denying are office visits for hair loss (regardless of the cause), pigmentation abnormalities of the skin, age and sun related damage to the skin resulting in wrinkling and other "aging" changes, and, in some cases, even acne. Among the procedures many insurance companies have begun denying are removal or destruction of benign (non-cancerous) growths of the skin such as skin tags, moles, keratoses (thickenings of the skin), hemangiomas (growths of blood vessels), telangiectasias (enlarged blood vessels) and warts (often regardless of the reason for the removal).
While not yet a routine occurrence, the situation has reached the point where we are no longer able to determine whether any specific procedure we perform may be rejected by any insurance company as being either "not medically necessary" or "cosmetic". Please remember that this determination on coverage is made by the insurance company; we (both you as the patient and we as the physicians) may feel that a condition requires treatment or a lesion needs to be removed, but that does not necessarily mean the insurance company will provide coverage or payment for the treatment or procedure.
The purpose of this letter is to inform you that, for any service we perform, there is the possibility that your insurance may deny coverage and payment after the claim has been submitted. We are notifying all of our patients that, in the event your insurance company denies payment for any of the services we perform for you, you are personally responsible for payment of these charges. Although we may be billing your insurance, we may still have to turn to you for payment if your insurance company refuses coverage for the above, or for any other, reasons.
Signing your name indicates your understanding and acceptance of the above.
X______
(signature of insured/responsible party)(date)
AUTHORIZATION TO RELEASE INFORMATION: I authorize Dermatology Center of Northwest Indiana PC to release information about my medical condition to (please circle as appropriate) SPOUSE PARENTS CHILDREN OTHER NO ONE
Please list names of persons authorized to receive medical information ______
______
X______
(signature of insured/responsible party)(date)