New Patient Form – Dr Diamond

Patient

First Name Last Name Initial

Address

Address City State ZIP

Home Phone

Cell Phone

Work Phone

SS #

Age

Birthdate

Sex

Male

Female

Status

Patient Employed By

Occupation

Race

White

Black/African American

Other

Ethnicity

Not Hispanic / Not Latino

Hispanic / Latino

Language Preference

English

Other

Under 18?

lf under 18, send bills to:

Name

Phone

Address

Address SS # City State ZIP

Physician Information

Please list your primary care/family physician's name:

Please list your primary care/family physician's address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like a report of your visit sent to the physician listed above:

Yes

INSURANCE INFORMATION

Name of Primary Insurance

Identification/Policy #

Group #

Subscriber's Name

Birthdate

SS #

Name of Primary Insurance

Identification/Policy #

Group #

Subscriber's Name

Birthdate

SS #

ASSIGNMENT AND RELEASE

Untitled*

I authorize Saye, Gette and Diamond Dermatology Associates, P.C. to furnish my insurance company with the information nec- essary to process my claim(s) for my medical and/or surgical services. I hereby assign payment from my insurance company to go directly to the physician, and I understand that I am responsible for any unpaid balance not covered by my policy.

Untitled*

I authorize the release of all medical information related to the above-named patient including but not limited to: (1) sub- stance abuse treatment; (2) mental health treatment; (3) HIV-AIDS related information, if such information is contained in the records. This authorization includes reports, correspondence, test results, and any other information in the records, whether generated by the authorized provider or another entity.

Untitled*

I request that payment of authorized Medicare benefits be made to Dr. Saye, Gette or Diamond for services furnished by that physician. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable for related services.