www.drvitulli.com - Patient Demographics Form

New Patient Demographics Form
Today’s Date*

MonthDay Year
Patient Name*

First Name Last Name
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of birth*

Month Day Year
Sex*
Marital Status
If married, spouses’ name*
Phone Numbers
Cell Phone Number*
Work Phone Number
Email Address
example@example.com
Race
Ethnicity
Language Spoken
Employer
Occupation
Do you work indoors / outdoors?
Social Security Number
Primary Care Physician
Primary Care Physician’s Phone Number
Please enter a valid phone number.
If minor, name of parent or guardian
Insurance Information
Primary insurance
ID Number
Group Number
Policy Holder
Relationship
Date of birth

Month Day Year
Do you have Secondary insurance*

YesNo
ID Number
Group Number
Policy Holder
Relationship
Date of birth

Month Day Year
Emergency Contact
Emergency contact name*
Phone Number*
Please enter a valid phone number.
How did you hear about us?
Whom may we thank for your referral to our office?
Assignment of Benefits

Please, initial each line item and sign below
Records Release: I authorize the release of my health information by the Practice for the purposes of my current treatment, including the release of information to my referring or primary care provider and other health care providers participating in my current treatment, or as otherwise necessary for the Practice to provide treatment to me. I authorize the release of medical information (including billing information) as necessary for payment purposes to my insurance company, and any other person or entity responsible for payment for my medical treatment. I authorize the release of my health information to business associates of the Practice as necessary for the purposes of the Practice’s health care operations. *
(initial)
Assignment of Benefits: I authorize payments of medical benefits to the Practice and its providers for services rendered to myself and/or my dependents*
(initial)
For Medicare Recipients Only
Medicare Authorization: I request that payments of authorized Medicare benefits be made on my behalf to the Practice for any services furnished to me by its providers. I authorize any holder of my medical information to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original.
(initial)
MEDIGAP: I request that payments of authorized MEDIGAP benefits be made on my behalf to the Practice for any services furnished to me by its providers. I authorize any holder of my medical information to release to the MEDIGAP carriers any information needed to determine these benefits payable for related services. I understand I may refuse to sign this authorization and realize this may result in a delay of treatment and/or have potentially adverse health consequences. I understand I may change or revoke this authorization at any time.
(initial)
*

I certify that I have read and fully understand the procedural office policies of A Center For Dermatology, Cosmetic and Laser Surgery, including its Financial policy, and I agree to be bound by its terms.
Patient’s Name *

First Name Last Name
Patient’s Date of Birth*

MonthDay Year
Patient/Responsible Party Signature*

Clear
Date*

MonthDay Year

Privacy Protection
The Health Insurance Portability and Accountability Act (HIPAA) requires A Center For Dermatology, Cosmetic and Laser Surgery (Practice) to obtain your authorization to allow communications regarding your protected health information. This authorization gives permission to our staff to discuss your health care with a family member or any other individual that you may designate. It also allows us to leave recorded messages at your home, work, or on your cell phone related to your medical care and treatment, payment, appointment status, or follow-up. Please, list phone number(s) in order of preference for receiving appointment reminders and/or patient care calls:
Please, select type*

Home Phone NumberCell Phone NumberWork Phone NumberOther
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
Other Phone Number*
Please enter a valid phone number.
Please, select messaging preferences below*

No MessageMessage to callDetailed message
Please, check an applicable option below
I give permission to the Practice to contact me via e-mail with news announcements, events, and promotions.I choose to opt out of e-mail announcements
Email*
example@example.com
This authorization allows A Center For Dermatology, Cosmetic and Laser Surgery to discuss all aspects of my protected health information with the individuals listed below: *
The Notice of Privacy Practices is available for your review at the office. Please, ask our staff if you wish to obtain a copy for your records.
Patient’s Name *

First Name Last Name
Patient’s Date of Birth*

MonthDay Year
Patient/Responsible Party Signature*

Clear
Date*

MonthDay Year
Should be Empty:

New Patient Demographics Form

Phone Numbers

Insurance Information

Emergency Contact

Assignment of Benefits

For Medicare Recipients Only

Privacy Protection

Please, check an applicable option below