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RESPONSIBLE PARTY INSURANCE POLICY HOLDER

If the patient is the responsible party/policy holder, please check here & omit Lines 1-C and 2-C

B

C

B

C

IF YOU HAVE NO INSURANCE, PLEASE CHECK HERE 

It is the policy of this office that the parent accompanying a child for treatment will be held responsible for all bills. Please complete the following information if you are the accompanying parent.

YOUR NAME: 

ADDRESS: 

What PHARMACY do you prefer to use?

MY SIGNATURE BELOW AUTHORIZES ALL OF THE FOLLOWING:

1. My consent for Dermatology of Southeastern Ohio, Inc. to bill my insurance carrier according to the information I have provided. I have provided the most current insurance infortion as well as the appropriate cards. I unsderstand that all balances are my responsibility, whether covered by insurance or not, including co-pays, co-insurance amounts, deductible amounts, and all patient responsibility amounts. If i am uninsured, I understand that I am responsible for payment of all charges for services provided.

2. My consent for Dermatology of Southeastern Ohio, Inc. to release medical information as needed to the insurance companies listed in my demographics, other providers involved in my care, and to any physician listed here:

3. My consent for Dermatology of Southeastern Ohio, Ivnc. to obtain my medication information from my pharmacy.

4. My consent for Dermatology of South eastern Ohio, Inc. to examine me and, if needed, render treatment after the provider explains it to me.

5. My consent for a skin biopsy if needed. I understand the provider will discss this with me in advance.

6. Acknowledgement of receipt of Notice of Privacy Practices (HIPPA).

7. My consent for Dermatology of Southeastern Ohio, Inc, to share, discuss my medical information and financial account with the following person(s).:

I HAVE READ AND UNDERSTOON ALL OF THE ABOVE ITEMS.