For an appointment, call (218) 454-7546 or (888) 841-2897
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For an appointment, call (218) 454-7546 or (888) 841-2897
Adult Registration Online Forms

Emergency Contact

Photo ID

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Primary Insurance Information

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Policy Holder (if other than patient)

Secondary Insurance Information

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Maximum upload size: 8.39MB
Policy Holder (if other than patient)

Authorization for Release of Information and Financial Responsibility

I hereby assign payment of authorized medical benefits to include major medical benefits to which I am entitled: To be made on my behalf to Dermatology Professionals, PA For any services furnished me by that Practitioner. I authorize release of medical information needed to determine these benefits payable to related services. I understand that I am financially responsible for all charges whether or not paid by said insurance. I understand copayments are due on the day of services as required by my insurance carrier. This Facility does not deny any benefits or service because of race, color, national origin, age gender, and disability, religious or political beliefs. If you feel you have been discriminated against, you may file Complaint of Discrimination with the Administrator of this Facility. You will not suffer any penalty because you file a complaint. I hereby acknowledge that I have been offered a copy of both the Dermatology Professionals, PA Financial Policy and the Notice of Privacy Practices.

By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events. I consent to the receiving multiple messages per day from my healthcare provider, when necessary. I consent to allowing detailed messages being left on my voicemail, answering system, or with another individual, if I am unavailable at the number provided by me.

Photographs: I hereby give permission to my provider or any assistant designated, to take photographs to enhance my medical record and for diagnostic/monitoring purposes. I understand that they may show them to other health professionals to assist with my care.

I permit a copy of this authorization to be used in place of the original.