*Patient Name :

Last name

Middle name

First name

I prefer to be called :

Birthday :

Age:

Gender : Male Female

*Address:

				City
State		Zip		APT#

*Email Address:

*Home phone #:

()- -

Social security#:

How did you hear about us?

Whom may we thank for referring you?

Guardians and Child's Details

Mother's Name :

Last name

Middle name

First name

Birthday :

Age:

Address:

				City
State		Zip		APT#

Social security#:

Cell phone #:

()- -

Work phone #:

()- - -

Father's Name :

Last name

Middle name

First name

Birthday :

Age:

Address:

				City
State		Zip		APT#

Social security#:

Cell phone #:

()- -

Work phone #:

()- - -

In Case of Emergency Contact

His / Her name :

Work phone #:

()- - -

Cell phone #:

()- -

* Consent to Treat : I hereby consent to treatment by my dermatologist and understand that it may include an examination, treatment with an oral or topical medication, or a skin procedure such as a biopsy or destruction of a skin leison. I have been made aware of the patient protected healthcare information act and the statement of privacy of practices is posted in this facility

Responsible Party/Insurance Information

Insurance Co. name:

ID# :

Primary Insurance card holder :

Address :

				City
State		Zip		APT#

Home Phone :

()- -

Work phone #:

()- - -

Cell phone #:

()- -

Relationship :

Birthday :

Social security # :

Insured’s employer :

Address :

				City
State		Zip		APT#

* Release and Assignment of benefits: I hereby authorize the release of any and all medical information to my insurance carrier(s) or their representative, for purposes necessary in the adjudication or processing of any and all insurance claim(s) filed on my behalf & for which I am financially responsible. I further authorize all insurance benefits be paid to the provider rendering services on behalf of Daniel S. Achtman M.D./ Carmine G. McConnell M.D.

Financial Policy

We are dedicated to providing the best possible care and service to you. Your complete understanding of your financial responsibilities is an essential element of your care and treatment. If you have any questions about the following financial policy, please do not hesitate to discuss them with us.

Your Insurance

We make every effort to follow the guidelines required by your insurance company. However, every insurance contract is unique. If you do not inform us of any special requirements in your plan and we subsequently perform a service or test that is denied, we have no choice but to bill you directly for those charges. Every effort is made to file claims on your behalf with your insurance plan. Unfortunately, if we are unable to collect from your insurance company, you will be held financially responsible. Therefore, we encourage our patients to understand their particular insurance plan and to be proactive in assuring that their claims will be paid

If your insurance coverage changes, it is your responsibility to notify our office at the time of your appointment. Failure to do so may result in rescheduling of your appointment. In addition, we may not be a provider with your new insurance. You will then be treated as a cash patient and given a superbill in order to file your own claim.

You may receive a separate bill from an off-site laboratory (Ameripath , Southwest Dermatology, LabCorp, etc) for any lab test your physician may order. Please discuss any lab billing discrepancies with that laboratory.

Cancellations and Missed Appointments

We kindly request that you give us a minimum of 24 hours notice, if you are unable to keep your appointment. Failure to do so will result in a missed appointment fee. This fee is NOT covered by your insurance plan. The missed appointment fee schedule is as follows.:

MEDICAL $50.00

SURGICAL $100.00

COSMETIC $50.00

In the case of a prepaid package, one session will be deducted from the package.

Returned Check Fee

There will be a $35.00 charge for all returned checks.

Collections

If your account is turned over to our collection agency, you will be responsible for the collection fee charged to us by the agency in addition to your outstanding balance.

Your insurance card and driver’s license will be required at check in.

* I have read and understand the financial policy of the practice, and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice.

New Patient Registration
Print blank form to fill by hand
This is a form with four pages. Once you submit New Patient Registration part, please go to Patient Protected Health Authorization part using the link below. Thank You. Patient Protected Health Authorization

Adult Patient Details

Guardians and Child's Details

Responsible Party/Insurance Information

Financial Policy

Your Insurance

Cancellations and Missed Appointments