Clearview Dermatology Patient Registration

New Patient Registration
Patient Name *

First Name Last Name
Gender *

Male Female
Date Of Birth *

Month Day Year
Date
Guarantor Name If Patient is Under 18 (Person responsible for the bill).

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Best Contact Phone Number *

Area Code Phone Number
Phone Type *

Cell Home Work
Ok To Leave Detailed Messages *
Alternate Phone Number

Area Code Phone Number
Alternate Phone Type

Cell Home Work
Preferred e-mail for appointment reminders (type none if none). *
example@example.com
Health Insurance *

Blue Cross Blue Shield Tufts Medicare Medicaid Cigna Aetna Harvard Pilgrim United Healthcare Tricare Self Pay ($100 downpayment required)
Health Insurance policy/member Id# as it appears on your insurance card; *
If self-pay type 'none'.
Subscriber/Policy Holder Name *

First Name Last Name
Relationship to Subscriber *
Group Number from insurance card if applicable.
Secondary Health Insurance (Complete if you have a supplemental insurance) *

Blue Cross Blue Shield Tufts Medicare Medicaid Cigna Aetna Harvard Pilgrim United Healthcare Tricare Self Pay ($100 downpayment required) None
Secondary Subscriber/Policy Holder Name

First Name Last Name
I understand that if I do not have insurance I will be self-pay, and $100 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. Clear
Clearview Dermatology bills all insurance companies as a courtesy to our patients. I understand it is ultimately the parent/guardian responsiblity to ensure all services are paid in full.
By signing I acknowledge that I will be responsible for all charges. Clear
I authorize Clearview Dermatology, LLC (aka Leominster Dermatology, LLP) to release my medical diagnosis to my primary care physician, other health care facilitiy(s), or specialst(s) as necessary to coordinate my care.
Signature

Clear
I authorize any holder of medical or other inforation about me to release to the Social Security Administration/Health Care Financing Administration, its intermediaries/carriers, and/or any other health insurance carrier any information needed for this or related health insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of insurance benefits be made directly to the provider who accepts assignment.
Signature

Clear
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