Todays Date
Patients Last Name<br/>
Patient First Name
Patient's Date of Birth
Information Pertaining to Person Responsible For Account
Responsible Party Last Name
Responsible Party First Name
Responsible Party Middle Name
Responsible Party Date of Birth
Relationship to Patient
Responsible Party Social Security Number
Responsible Party Spouse
Street Address
City
State
Zip
Phone Number
Cell Phone Number
Email
Employer
Employer Phone
Please Choose from Drop Down List
Nearest Relative
Please Choose from Drop Down List
Name of Referral Source, ie Dr.. or Yellowbook
Any other family Members Being Seen in Clinic
If so Who ?
Insurance Information
Primary Insurance Co Name
Primary Insurance Address
Primary Insured Name
Primary Insured Social Security
Primary Insured Date of Birth
Primary Insurance Group #
Primary Insurance ID Number
Primary Insurance Deductible Amount
Primary Insured Relationship to Patient
Secondary Insurance Co Name
Secondary Insurance Co Address
Secondary Insured Name
Secondary Insured Social Security Number
Secondary Insured Date Of Birth
Secondary Insured Group Number
Secondary Insured ID Number
Secondary Insurance Deductible
Secondary Insured Relationship to Patient
Authorizations
Should your account become past due with our office, the undersigned will be responsible for paying any collection charges or attorney fees used in collecting your account.
By checking below I authorize Galesburg Dermatology Center to Release Information for the Adjudication of Insurance and as necessary for my Medical Treatment
Authorization for Treatment
By Checking Below I authorize my Insurance Company(s) to pay Dr. Fayman directly for services rendered.
Authorization for Payment
I authorize Galesburg Dermatology Center to contact me by the following methods. Check all that apply. You will be contacted only regarding your treatment or appointments.
Office Policies
We strive to inform you of the office policy and expectations every step of the way. If at anytime you are unsure of something please speak to a staff member to clarify. At this time we are providers for Medicare, BCBS PPO, Human and Tricare. All applicable co-pays and/or deductibles need to be paid at the time services are rendered, as part of your contract with these insurances. Your insurance card should tell you your co-pay and network. Should you still have questions, please ask for assistance or contact your insurance provider. New Patients who are not part of a contracted plan will be required to pay a deposit of the greater of 125.00 or 20% of charges for the first visit. Any additional charges can be billed to the insurance. After your first visit, you may, if additional visits are necessary pay your co-insurance or co-pay amount. As a courtesy we file both your primary and secondary insurance. Please Keep in mind that your insurance is a contract between you and the carrier, we are not a party in that. While we will do everything in our power to obtain payment from the insurance, you are ultimately responsible for the billed amount. Cosmetic procedures or those deemed cosmetic by your insurance are always paid in full at the time services are rendered. We strongly encourage you to discuss fees for surgery, cosmetic and non cosmetic procedures in advance as you do not want any surprise bills to pay. Should you have any special financial needs, they should be addressed prior to services being rendered. Any amount left owing greater than 90 days will be charged interest at the rate of 18%(1.5%per month) . For this reason you should follow up if you have not heard from your insurance within 45 days of your visit. Regardless of the reason for today's visit we encourage you to seek a full skin exam to screen for any possible malignancies. Ask Dr. Fayman if this is something you would be interested in.
In order to keep an orderly schedule and minimize wait time, an office visit fee will be charged for all missed appointments or cancellations with less than 24 hour notice. If a true emergency occurs, or if weather conditions exist exceptions may be made by the physician only. The Parent or Guardian accompanying minor children will be responsible for payment of services.
I have read, understand and agree to the terms outlined above, in Office Policies. By Accepting the terms I give Dr. Fayman authority for examinations and treatment concerning todays visit as well as any future visits I may require.
I agree to the policies as described in Office Policy
Date of Agreement