Amerejuve Yearly Patient Packet

Amerejuve Yearly Patient Packet
Name *

First Name Last Name
Date of Birth *

Month Day Year
Social Security Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *
Home Phone Number *
Please select

Minor Single Married Divorced Widowed Separated
If minor state parents or guardian name
Relationship
Patient/Parent/Guardian’semployer
WorkNumber
Emergency Contact
PhoneNumber
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number
Home Phone Number
Insurance Information
Name of Insured
Relationship
Date of Birth

Month Day Year
Social Security Number
Name of Insurance
ID Number
Additional Insurance Information:

No Yes
If yes please complete below:
Name of Insured
Relationship
Date of Birth

Month Day Year
Social Security Number
Name of Insurance
ID Number
Group Number
Union/Local Number
Authorization to release information: I hereby authorize the release to my insurance company of any information required in the course of my examination or treatment. This information may be released nor or in the future.

Authorization to pay Benefits to Physician: I hereby authorized and direct my insurance company to pay Amerejuve Dermatology any medical benefits which would be payable to me for their services.

I understand I am financially responsible for the charges not covered by this authorization.

Authorization for Medical Treatment: I authorize you to give me reasonable and proper medical care by today’s standards.
Patient Signature

Clear
Date

Month Day Year
The best way to reach me is my:

Home Number   (000) 000-0000
Cell Number   (000) 000-0000
Work Number   (000) 000-0000
Email Address   Email

If you are unable to reach me, you may:

    Leave a detailed message   Leave a message asking me to return your call
Power of Attorney
I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect the care I receive from the provider, my eligibility for benefits, or enrollment, payment or coverage of these services.
Printed Name
Patient Signature

Clear
Date

Month Day Year
If applicable, legal representatives sign below:

By signing this form, I acknowledge that I am the legal representative of the member identified above and will provide written proof (e.g. Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the member’s behalf with respect to this authorization form.
Printed Name of Legal Representative
Signature of Legal Representative

Clear
Date

Month Day Year
Amerejuve Dermatology

713-960-6262
HIPAA Release of Information Authorization Form

Amerejuve Dermatology
I hereby authorize Amerejuve Dermatology and its affiliates, employees, and agents to release information to:
Spouse
Name of the spouse you wish to release information to
Family
Name of the family member you wish to release information to
Other
Name of any other person you wish to release information to
Please select the box below if you wish information is NOT to be released to anyone.

Information is NOT to be released to anyone.
My or my legal dependents person health information maintained by Amerejuve Dermatology (e.g., Information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided and which identifies me or my legal dependents name, address, social security numbers, member ID number) except the following information:
Enter text here if any
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if Amerejuve Dermatology, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Patient Name
Patient Signature

Clear
Date

Month Day Year
Amerejuve Dermatology

713-960-6262
Authorization for Release of Information
Name of Patient

First Name Last Name
Date of Birth

Month Day Year
Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize Amerejuve Dermatology to disclose my medical records to:
Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Fax Number
I authorized Amerejuve Dermatology to obtain my medical records from:
Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Fax Number
I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released prior to the written revocation. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to consent under my policy. Unless otherwise revoked, this authorization will expire on the following date: MM/DD/YYYY. If I fail to provide an expiration date, this authorization will expire in 60 days from date of signature.

I understand that authorizing the disclosure of this health information is voluntary. I understand I can refuse to sign this authorization. I understand any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. I understand that if I have been treated for drug or alcohol abuse my records regarding this treatment are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2 and cannot be disclosed without my written consent unless otherwise provided for in the regulations
Patient Name
Patient Signature

Clear
Date

Month Day Year
Witness Name
Witness Signature

Clear
Date

Month Day Year
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any error or omissions that I may have made in completion of this form.
Patient Signature

Clear
Date

Month Day Year
Should be Empty:

Amerejuve Yearly Patient Packet

Insurance Information

If yes please complete below:

Power of Attorney

Amerejuve Dermatology

HIPAA Release of Information Authorization Form

Amerejuve Dermatology

Authorization for Release of Information