Patient Registration Form

Dr. Tobias Patient Registration Form

This is a secure HIPAA compliant form.
Scheduled Date of Your Appointment

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone #*
Please enter a valid phone number.
Home Phone #
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age
Social Security #
Marital Status
Occupation
Next of Kin's Name*

First NameLast Name
Next of Kin's Mobile Phone #*
Please enter a valid phone number.
Next of Kin's Relationship to Patient*
How did you hear about Dr. Tobias?

Insurance Information
Upload Insurance Card - Front

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Upload Insurance Card - Back

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Insurance Provider*
Enter "none" for no insurance.
Insurance ID #
Insurance Group ID #
Medical Insurance Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Social Security #
Policy Holder Employer/Occupation
Relationship to Insured*

SelfSpouseDependent
Pharmacy Information
Pharmacy Name*
If you don't have a routine pharmacy, choose one closest or most convenient for you.
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone #*
Please enter a valid phone number.

Authorization & Consent
Insurance Authorization & Assignment*

I hereby authorize Dr. Geoffrey W. Tobias to furnish information to insurance carriers concerning my illness and treatment, and hereby assign him to all payments for medical service rendered.
Patient/HIPAA Consent*

I agree to the privacy policy below.
The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about your treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you to choose to refuse to disclose your Personal Health Information (PHI). If you chose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form or would like a copy of this HIPAA consent, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
Patient signature acknowledging authorization & consent to the above*

Clear
Patient Name*

First NameLast Name
Consent for Pictures and/or Videos
Because part of the process in selecting a cosmetic surgeon is dependent upon patients viewing examples of the surgeon’s work, we ask that you consider granting permission to use your photos in any or all of the following ways. Please check all that apply.

Sharing your photos with other patients.Use for professional instruction at meetings or online educational seminars.“Before and After” surgery examples for our website and social media accounts.Videos for use on our website and social media accounts.
Consent*

I give consent to use my photos and/or videosI do not give consent to use my photos and/or videos
Patient Signature

Clear
Upload your ID - Front

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Upload your ID - Back

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Should be Empty:

Dr. Tobias Patient Registration Form

Insurance Information

Pharmacy Information

Medical History

Authorization & Consent

Consent for Pictures and/or Videos