Patient Registration Step 1

Please complete all questions and submit 24 hours prior to your appointment time. Your forms will be emailed directly to us when you click on the Submit button. * Required fields.

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PATIENT INFORMATION


*Patient Name:

*first	mi	*last
Name Called By:

*Address:

			- -
*city	*state	*zip	SSN#

Email:			Pharmacy Phone Number:

*Sex: (select one)	*Home Phone:	Work Phone:	Cell Phone:


*Date of Birth: (MM -DD - YYYY)	Marital Status:	Primary Care Physician:
- -
Referred By:

Employer:	Occupation:

How did you hear about our office?

Other family members seen in our office?

SPOUSE INFORMATION


Spouse Name:	SSN#	Employer:	Work Phone:
	- -

EMERGENCY CONTACT


Name:	Relationship:	Phone:

MINOR INFORMATION (please complete only if patient is a minor)


Father/Guardian:	Employer:	Phone:

Mother/Guardian:	Employer:	Phone:

PRIMARY INSURANCE


Insurance Company:	Insurance Type:	Insured (Employee's) Name:


Date of Birth:	Relationship:	Member ID#:	Group# or Employer's Name:


Copay:	Deductible:	Effective Date:
$	$

Claims Address:


city	state	zip

Phone:

SECONDARY INSURANCE


Insurance Company:	Insurance Type:	Insured (Employee's) Name:


Date of Birth:	Relationship:	Member ID#:	Group# or Employer's Name:


Copay:	Deductible:	Effective Date:
$	$

Claims Address:


city	state	zip

Phone:

MEDICARE/MEDICAID


Medicare#:	Medicaid#:

PAYMENT

Who is the resposible party for payment?

Method of payment for co-payment, deductible and/or co-insurance?

*Patient Initials

I authorize the release of medical information to any carrier as necessary to process insurance claims or to the Social Security Administration and CMS or its intermediaries 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. Regulations pertaining to Medicare assignment of benefits apply.

I have read and agree to my obligations set forth in the Payment Policy of Dermatology Center of Atlanta.

*Signature Box:

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