EmailMe Form - FACE SHEET/PATIENT INFORMATION

Name *

First Last

Date of Birth *

MM / DD / YYYY

Sex

Address

Street Address City State / Province / Region Postal / Zip Code

Email Address

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Social Security Number

Employer

Employer Phone

### - ### - ####

Marital Status

Occupation

Preferred Pharmacy

Emergency Contact

First Last

Emergency Contact Phone

### - ### - ####

Emergency Contact Relationship

Primary Physician

Referring Physician

Primary Insurance *

ID Number

Cardholder's Name

First Last

Cardholder's SS#

Relationship to Patient

Cardholder's Date of Birth

MM / DD / YYYY

Cardholder's Employer

Do you have an advanced care plan such as a Living Will or Power of Attorney?

Yes

No

If yes, please specify

Race

Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Unreported/Refuse to report

Primary Language

RELEASE OF MEDICAL INFORMATION CONSENT

I, the patient or his/her legal representative, do hereby authorize Southeastern Dermatology Group, P.A., to use or disclose my health
related information as outlined in the Privacy Notice that has been provided to me. I have received, read, and understand the
information detailed in the Privacy Notice.

I hereby give permission to disclose, discuss and speak with the individuals listed below regarding my personal health information or
treatment.

I understand that unless specifically listed below, Southeastern Dermatology Group, P.A. cannot speak to any individual
concerning my medical or financial information including, but not limited to appointments, test results, prescriptions, school or work
excuses. This includes my spouse, children, siblings, or parent, if I am 18 years or older. I understand that I can amend this list at any time by
submitting a request in writing.

I consent to the release of my health information to the following individual(s):

Name

First Last

Phone

### - ### - ####

Name

First Last

Phone

### - ### - ####

Name

First Last

Phone

### - ### - ####

Health Information Disclosure Restriction Requests:

Date Time

MM / DD / YYYY

Signature of Patient/Authorized Representative

Clear

Please initial each section below to indicate you have read and understand the information:

ASSIGNMENT OF INSURANCE AND FINANCIAL RESPONSIBILITY
I do, hereby, authorize payment of all insurance benefits, basic and major medical, for the services I recevie, to be made directly to Southeastern Dermatology Group. I understand that I am ultimately responsible for any unpaid balance or non-covered service. I agree to pay all costs of collecting, securing, or attempting to collect or secure payment, including reasonable attorney fees or collection agency fees. *

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STATEMENT AUTHORIZING PAYMENT BY MEDICARE AND OTHER INSURANCES
I request that payment of authorized Medicare or other applicable private insurance benefits be paid directly to Southeastern Dermatology Group
for services provided under their care. I also authorize Southeastern Dermatology Group to release necessary medical information to my insurance
company, its agents, or any third party in order to determine payable benefits for the services rendered. *

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CONSENT FOR MEDICAL SERVICES
I authorize Southeastern Dermatology Group to render treatment to me/my dependent for dermatological care/medical procedures as may
be deemed necessary. *

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DIGITAL PHOTOGRAPHY
I authorize the medical providers and staff of Southeastern Dermatology Group to take digital photographs that relate to my care. Southeastern
Dermatology Group will only disclose information relevant to current treatment and is authorized to use photographs for educational or
publication purposes, provided my identity is protected. I may change this authorization at any time. *

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REFERRALS/AUTHORIZATIONS
I understand that if my insurance company requires a referral, I am responsible for obtaining a referral prior to my visit. If I do not have a referral at
the time of service, no services will be rendered until I obtain a referral or sign a waiver of financial responsibility. Payment in full will be required at the
time of service. *

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PRIVACY POLICY NOTICE
A copy of Southeastern Dermatology Group’s Privacy Notice has been provided to me which outlines how my private health information may be
used or disclosed and my rights related to the use and disclosure of this information. I have read and understand the information outlined in the
notice. *

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MISSED APPOINTMENTS
Our office requires a 24-hour notice for cancellations. Failure to do so may result in a $25 fee for medical appointments and a$50 fee for
cosmetic appointments. *

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ePRESCRIBING CONSENT
ePrescribing is a federally mandated initiative that requires all physicians to prescribe in this manner. ePrescribing software sends prescriptions
over the internet to your pharmacy in a safe, secure way, utilizing secure technology to protect the privacy of your personal information.
ePrescribing software also allows our providers to see important information, such as drug interactions and your prescription history. *

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ELECTRONIC MESSAGES
If you have provided your email address, we would like to send you periodic news and information. This would include satisfaction surveys,
information about new treatments and procedures, skin health information, physician announcements and special events. If you do not wish to
receive this news, click the UNSUBSCRIBE function at the bottom of the email, and we will remove your address from this list. *

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CONSENT FOR LAB SERVICES
Southeastern Dermatology Group uses a centralized laboratory in Panama City, Florida, to process biopsy specimens. It is my responsibility to ensure that these lab services are in network with my insurance company. If the lab is out of network, I will notify Southeastern Dermatology Group in advance. I am responsible for any out of network fees associated with lab processing if I have not made arrangements in advance with Southeastern Dermatology Group. *

Enter your initials

Date

MM / DD / YYYY

Name

First Last

RELEASE OF MEDICAL INFORMATION CONSENT

I hereby give permission to disclose, discuss and speak with the individuals listed below regarding my personal health information or treatment.

I consent to the release of my health information to the following individual(s):

Please initial each section below to indicate you have read and understand the information:

I hereby give permission to disclose, discuss and speak with the individuals listed below regarding my personal health information or
treatment.