Telehealth New Patient Registration (Minor) Minor's Full Name * Gender * Male Female Social Security # Date of Birth * Primary Contact Name Relationship Preferred Phone # * Home Cell Preferred Language English Other Race Caucasian Native American Black Hispanic Asian Hawaiin/Pacific Islander Other RESPONSIBLE PARTY / GUARANTOR FOR MINOR Full Name * Relationship * Gender * Male Female Social Security # * Date of Birth * Mailing Address * City * State * Zip Code * Preferred Phone # * Home Cell Alt Phone # Home Cell Place of Employment Work Phone Email Address * Additional Contact / Parent Full Name Relationship Gender Male Female Social Security # Date of Birth Mailing Address City State Zip Code Preferred Phone # Home Cell Alt Phone # Home Cell Place of Employment Work Phone Email Address Primary Insurance Information Upload copy of insurance card Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 8MB Name of Insurance Copay $ Group # ID # Policy Holder Full Name * Relationship * Male Female Date of Birth * Social Security # Same address as Patient Different Address Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Phone Number Home Cell Place of Employment Work Phone # Secondary Insurance Information Upload copy of insurance card Drop a file here or click to upload Choose File Maximum upload size: 8.39MB Name of Insurance Copay $ Group # ID # Policy Holder (If other than patient) Full Name Relationship Male Female Date of Birth Social Security # Same address as Patient Different Address Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Phone Number Home Cell Place of Employment Work Phone # 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. Signature * Draw It Type It Clear Date * Submit
