Clearview Dermatology Patient Registration

PLEASE ALLOW 2-3 BUSINESS DAYS FOR PROCESSING ONLINE REGISTRATIONS*

I UNDERSTAND THAT IF MY APPOINTMENT IS WITHIN THE NEXT 1-2 BUSINESS DAYS THIS REGISTRATION MAY NOT BE PROCESSED AT THE TIME OF CHECK-IN.

Patient Name*

First NameLast Name

This is a fill in the blanks field. Please add appropriate blank fields and text.

Gender*

MaleFemale

Date Of Birth*

Date

Guarantor Name If Patient is Under 18 (Person responsible for the bill).

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

By my signature below, I authorize the Practice to communicate with me by phone (using the numbers I’ve provided below) and to disclose my general health information (and my highly confidential information if necessary, with any exceptions listed below) on my home answering machine/voicemail and on my cell phone voicemail, and to my spouse/partner, children, and the following additional family and friends listed below. Signature*

Best Contact Phone Number*

Area CodePhone Number

Phone Type*

CellHomeWorkOther

Alternate Phone Number

Area CodePhone Number

Alternate Phone Type

CellHomeWorkOther

Type N/A if not applicable.
Spouse/Partner Name blanks*
Spouse/Partner Phone Number: Area Code Phone Number

Type N/A if not applicable.
Child Name blanks*
Phone Number: Area Code Phone Number

Type N/A if not applicable.
Additional person (friend/sibling, etc) name: blanks
Phone Number:   Area Code   Phone Number
Relationship:   *

Preferred e-mail for appointment reminders (type none if none@none.com).*

example@example.com

The Practice is not authorized to disclose the following highly confidential information if applicable:

HIV/AIDS related information and/or recordsPsychotherapy notesOther mental health information, communication and/or recordsInformation acquired by any social worker consulting me in their professional capacityContain communications between myself and any psychotherapist, psychologist, or allied mental health professional.Genetic testing information and/or records.Contain any blood alcohol test results.Related to venereal disease.Regard a child born out of wedlock

Health Insurance*

Health Insurance policy/member Id# as it appears on your insurance card;*

If self-pay type 'none'.

Subscriber/Policy Holder Name*

First NameLast Name

Relationship to Subscriber*

Group Number from insurance card if applicable.

Secondary Health Insurance (Complete if you have a supplemental insurance)*

Secondary Subscriber/Policy Holder Name

First NameLast Name

I understand that if I do not have insurance I will be self-pay, and $250 down payment will be required at the time of service. I understand that I will be balance billed any additional charges.

By signing, I acknowledge I understand the self pay policy.

Acknowledgment and General Consent
1.      ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:
By my signature below, I agree to receive in paper or electronic form and hereby acknowledge that I have received from Leominster Dermatology, LLP d/b/a Clearview Dermatology (Practice) a copy of the Practice’s Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the Practice and how I may obtain access to and control this information.

2.      CONSENT TO DISCLOSE MY GENERAL HEALTH Information:
By my signature below, I hereby authorize the Practice to disclose my general health information so that the Practice may treat me, seek payment from third parties for such treatment, and generally carry on the health care operations of the Practice (e.g., quality assurance). I also authorize the Practice to disclose my general health information to insurers and providers outside of the Practice when necessary for purposes of my treatment, payment for that treatment, and for their health care operations.

3.   CONSENT TO DISCLOSE MY HIGHLY CONFIDENTIAL INFORMATION:
I understand that my medical record currently contains or may contain in the future the following types of highly confidential information, and by my signature below, I specifically consent to the disclosure of the following types of highly confidential information so that the Practice may treat me, seek payment from third parties for such treatment, and generally carry on the health care operations of the Practice (e.g., quality assurance):
·        information related to confidential communications with a psychotherapist, psychologist, social worker, sexual assault counselor, domestic violence counselor or other allied mental health professional or human services professional
·        information about genetic testing
·        information about venereal disease(s)
·        abortion consent form(s)
·        mammography records
·        information about family planning services
·        substance use disorder information that is not protected by 42 CFR Part
·        if I am an emancipated minor, information about my treatment and diagnosis for which I have consented as an emancipated minor (except that this information shall not be disclosed to my parents)
·        information about research involving controlled substances

I also authorize the Practice to disclose such information to insurers and providers outside of the Practice when necessary for purposes of my treatment, payment for that treatment, and for their health care operations.

4.                  CONSENT TO ADDITIONAL COMMUNICATIONS:
Please refer to the Practice’s Consent to Communications Form.

5.                  CONSENT TO OBTAIN INFORMATION ABOUT ME:
By my signature below, I authorize the Practice to obtain information about me from my other health care providers, my health plan and my pharmacy, including, but not limited to, my medication history. I understand that those parties may require me to sign additional forms before disclosing my information to the Practice. I understand that all such information obtained by the Practice will become part of my record at the Practice.

6.                  CONSENT TO TAKE IMAGES AND RECORDINGS
By my signature below, I hereby consent to the taking and recording of photos, videos and other images (collectively, “Images and Recordings”) of me by the Practice in any format, and I hereby acknowledge that the Practice may use and disclose such Images and Recordings in accordance with this Form and any other authorization granted by me, and in accordance with the Practice’s Notice of Privacy Practices.

7.                  CONSENT TO TELEMEDICINE
By my signature below, I acknowledge that: (i) from time to time, the Practice may recommend the use of electronic and telecommunication technologies (e.g., phone, video, teleconferencing, videoconferencing, electronic transmission of images, patient portal, and/or other technologies) to communicate with me for the purpose of providing health care services to me (“Telemedicine”) instead of in person (face-to-face) communications and visits; (ii) I consent to and permit the Practice to use Telemedicine in my care, (iii) reasonable efforts will be made to protect my privacy, though there may be risk of inadvertent disclosure of my information in the event of a technology malfunction or breach, (iv) I can ask questions and discontinue the use of Telemedicine at any time I choose, and (v) if I am not improving and/or I have serious health concerns, I will seek immediate medical attention at an emergency facility and I will not use Telemedicine in place of doing so.

8.                  CONSENT TO FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS:
By my signature below, I understand, acknowledge and agree that I am responsible for paying for all care that I receive at the Practice, and if my insurance company or benefit plan denies payment, in part or in full (because I do not have the required referral or for any other reason), or otherwise does not cover the full cost of such care for any reason, or I do not have insurance, I must pay the remaining balance and I will be personally financially responsible for the full payment of my account.

Also by my signature below, I hereby assign and transfer to the Practice all health care benefits payable by my insurance company or benefit plan and related rights, including my rights to appeal any denial of benefits or limitation of coverage existing under my insurance policies or benefit plans. I hereby consent to and irrevocably authorize and direct my insurance company or benefit plan (including Medicare, Medicaid/MassHealth and/or any other third-party payment program) to pay benefits for services provided to me by the Practice directly to the Practice, and I appoint the Practice to act as my authorized representative in requesting an appeal from my insurance company or benefit plan regarding any denial of payment. I understand that this assignment does not relieve me of any responsibility I may have for payment of charges not paid by my insurance company or benefit plan, unless otherwise provided in the terms of an agreement between the Practice and the insurance company or benefit plan.

Signature*