PATIENTINFORMATION

LastName_________________________FirstName_______________________M.I.______MaritalStatus:oMarriedoSingleoDivorcedoWidowed

SocialSecurityNo.:______-_______-______BirthDate:______/______/______Sex:oMoFPlaceofBirth:_________________________________________________________________PreferredLanguage:___________________________Race:___________________________EmergencyContactName:___________________________Relationship:________________

EmergencyContactPhone:(_____)_____________

PleasecheckpreferredcontactnumberoHomePhone:(_____)_____________oWorkPhone:(_____)______________oCellPhone:(_____)_______________oOtherPhone:(_____)_____________

DoyouauthorizeDermatologySpecialists,Inc.toleavedetailedmessages?

oYES,youhavemyconsenttoleavedetailedmessages.oNO,youdonothavemyconsenttoleavedetailedmessages.

EmailAddress:________________________________________________________________

oYes,Iwouldliketoreceiveemailswhichmayincludepracticeandphysicianupdates,marketingmaterials/promotionsfromthirdpartiesorourpractice,informationonmedical

advancementsand/orinformationonourclinicaltrials.MailingAddress:_______________________________________________________________City:__________________________________State:______________Zip:_______________Employer:_______________________________Occupation:__________________________

INSURANCEINFORMATIONPrimaryInsuranceCarrier:___________________PolicyHolderName:___________________IDNumber:______________________________GroupNumber:_______________________SecondaryInsuranceCarrier:________________PolicyHolderName:___________________IDNumber:______________________________GroupNumber:_______________________

RESPONSIBLEPARTY(ifdifferentfrompreviouspage)

LastName_________________________FirstName_______________________M.I.______BirthDate___/____/_____SocialSecurityNo.:______-______-______Sex:oMoF

MailingAddress:_______________________________________________________________City:__________________________________State:______________Zip:_______________

oHomePhone:(_____)_____________oWorkPhone:(_____)_______________oCellPhone:(_____)_______________oOtherPhone:(_____)______________

Youhavemyauthorizationtoreleasedetailedinformationincludingresultsto:oMySpouse:__________________________oFamilyMember:______________________oMyDoctor:__________________________oOther:______________________________IunderstandIhavetherighttorevokethisauthorizationinwriting.Iunderstandtherevocationwillnotapplytoinformationthathasalreadybeenreleasedinresponsetothisauthorization.Iunderstandtherevocationwillnotapplytomyinsurancecompanywhenthelawprovidesmyinsurerwiththerighttocontestaclaimundermypolicy.TorevokeanauthorizationImayfilloutarevocationformavailableatDermatologySpecialists,Inc.orwritealettertoDermatologySpecialists,Inc.

ByinitialingbelowIacknowledgethatIhavereceived,understand,andaminagreementwiththefollowing:

____ FINANCIALPOLICY ____ RECORDRELEASE____ CHECKPOLICY ____ NOTICEOFPRIVACYPOLICY____ HMOPLANS ____ NOSHOW/CANCELATIONPOLICY____ COSMETICPROCEDURES

ADULTTREATMENTCONSENT

____________________________________________________________________________Date:________________PatientName(PRINT) PatientSignature

MINORTREATMENTCONSENTI give the doctors and staff at Dermatology Specialists, Inc. permission to treat____________________________________ in my absence for all future appointments._______________________________________________________Date: ________________

Signatureofparentorlegalguardianofminor

FINANCIALPOLICYSinceyourinsurancepolicyisacontractbetweenyouandyourinsurancecompany,youareresponsibleforthecostforservicesyoureceivefromDermatologySpecialists,Inc.Ifourofficehasacontractwithyourinsurancecompany,wewillbillyourinsuranceforyou.Itisyourresponsibilitytoknowwhetherpriorauthorizationisrequiredbyyour insurancecompanyprior toanyofficevisitsorsurgery. This requirementmayaffectyourbenefitsandamountspaidbyyourinsurance.Pleaseinformthisofficeifsuchauthorizationisrequiredbeforeservicesarerendered.Youmusthaveyourinsurancecardoryouwillberequiredtomakeapaymentatthetimeofservice.Itisyourresponsibilitytonotifyusifyourinsurancetype,primaryphysician,primarymedicalgroup,terminationoranyotherchangeshaveoccurredthatcouldaffectyourinsurancecoverageforservicesabouttobeprovided.Ifwearenotinformedpriortorenderingservices,youmayberesponsibleforthecostoftheservices.WeacceptassignmentforallMedicareandTricarepatients.Co-paymentsanddeductiblesaredueandpayableateachvisit.A$15.00processingfeewillbeaddedtoyouraccountifitissubmittedtoourcollectionagencyfornon-paymentorifyourcheckisreturnedtousbyyourbank.

CHECKPOLICYDermatologySpecialists,Inc.willelectronicallydebityouraccountfortheamountofthecheckplusaprocessingfeeof$25.00onchecksthatarereturnedbythebankasunpaid.Thisfeerepresentsthecostofhandlingandcollectingthedishonoredcheck.

HMOPLANSYouunderstandthatpaymentoftheseservicesisdependentonpriorauthorizationsecuredfromyourprimarycarephysicianorhealthplanandyourcurrenteligibilityofbenefitsfromyourinsurancecarrier.Shouldeitherrequirementnotbemet,youarefinanciallyresponsiblefortheservicerendered.

COSMETICPROCEDURESCosmeticproceduresarecashonlyandcannotbebilledtoinsurance.Theseproceduresincludebutarenotlimitedto:Botox,Collagen,Restylane,HairRemoval,FacialVeins,SpiderVeins,andSkinTagsorbenigngrowths.

RECORDRELEASEANDASSIGNMENTOFBENEFITSI herebyauthorizeDermatology Specialists, Inc. to release relevant information regardingmy care tootherphysiciansinvolvedinmycaseand/orinsurancecompaniesholdingpoliciesonme.IauthorizemyinsurancecompanytodirectlyremitpaymenttoDermatologySpecialists,Inc.formedicalorsurgicalservicesprovidedandbilledbyDermatologySpecialists,Inc.

NOTICEOFPRIVACYPOLICYIherebyacknowledgethismedicalpractice’sNoticeofPrivacyPractices.Ifurtheracknowledgethatacopyofthecurrentnoticewillbeavailabletomeinwritinguponmyrequest.AnyamendedNoticeofPrivacyPracticeswillbeavailabletomeateachappointmentuponmyrequest.

NOSHOW/LATECANCELLATIONPOLICYNoShowPolicy:Ifyoudonotarrivetoyourappointment,itwillberecordedinyourchartandconsidereda“noshow”.Ifyounoshow,youwillbechargedaNoShow/LateCancellationFee.Latecancellations(lessthan24hoursnotice)areconsidereda“noshow”andwillbechargedtheNoShow/LateCancellationFee.Exceptionsmaybemadeinsomecircumstances,butaredeterminedbytheprovider.Cancellationsmademorethan24hoursinadvanceofyourscheduledappointmenttimewillnotreceiveaNoShow/LateCancellationFee.CancellationofanAppointment:Pleasecalltheofficepromptlyifyouareunabletoattendanappointment,sothistimecanbegiventoanotherpatientinneedoftreatment.Ifitisnecessarytocancelyourappointmentpleasecontactusatleast24hoursinadvance.Weappreciateyourattentiontothismatterasourappointmentsareinhighdemand.NoShow/LateCancellationFees:

• MedicalandCosmeticAppointment:$50.00• SurgeryAppointment:$150.00• MohsSurgeryAppointment:$300.00

If you no show to an appointment, you are required to pay anyNo Show / Late Cancellation Fees beforeschedulinganyfurtherappointments.IunderstandthispolicyandauthorizeDermatologySpecialists,Inc.toassessNoShow/LateCancellationFeesaccordingtotheaboveoutlinedpolicy.