PATIENT FORMS

PATIENT'S NAME (AS IT APPEARS ON INSURANCE CARD)

IT IS VERY IMPORTANT THAT YOU PROVIDE US WITH YOUR COMPLETE, ACCURATE, AND CURRENT INSURANCE COVERAGE. We are participating provider with many insurance companies. As a part of our contracts, we are required to file your claims to these companies. If you have insurance through your employer that insurance is primary and must be filed first. Insurance through your spouse's employer is secondary and will be filed after we hear from the primary insurance.

YOUR ARE RESPONSIBLE FOR ANY UNPAID BALANCES. WE MUST HAVE A COPY OF ALL INSURANCE CARDS.

IT IS VERY IMPORATANT THAT YOU PROVIDE US WITH YOUR COMPLETE, ACCURATE, AND CURRENT INSURANCE COVERAGE. We are a participating provider with many insurance companies. As a part of our contracts we are required to file your claims to these companies. WE MUST HAVE A COPY OF ALL INSURANCE CARDS.

NO INSURANCE

I do not have insurance coverage. I will not file to any insurance company for reimbursement. I understand that I am responsible for my bill at the time of service. We accept Amercian Express, MasterCard, Visa, and Discover.

MANAGED CARE INSURANCE & MEDICARE

If we are a participating provider with your insurance company, you are responsible for any allowable copayment and/or deductible. I authorize Chris M. Peterson, MD, PA  to release to my insurance companies any information required for service provided. I permit a copy of the authorization to be used to place of the original and request that payment of insurance benefits be assigned to Chris M. Peterson, MD, PA. I agree to pay all copays, deductibles and balance of allowable fees.

ALL OTHER INSURANCE

As a professional courtesy, we will file your insurance. We cannot assume responsibility of your payment by your insurance carrier, nor can we accept their payment as payment in full. I understand that my insurance is a contractual agreement between myself and my insurance company. I agree to pay any amount not paid by my insurance companies. I permit a copy of the authorization to be used in place of the original and request that payment of insurance benefits be assigned to Chris M. Peterson, MD, PA.

FOR PATIENT SERVICES REFERRED FOR LAB OR PATHOLOGY SERVICES

I authorize Chris M. Peterson, MD, PA  to forward my insurance information to such labs. I authorize Dermatology Consultation Service, LabCorp, Quest, Miraca or Pathology Consultants to release to my insurance companies any information required for services provided. I permit a copy of this authorization to be used in place of the original and request that payment of insurance benefits be assigned to them.

We send out patient statements at the beginning of each month. Patients with managed care insurance are billed after insurance processes their claim. Unpaid patient balances over 90 days old are subject to collection proceedings and dismissal from the practice.

ACKNOWLEDGEMENT OF RECEIPT OF OUR NOTICE OF PRIVACY PRACTICES

Chris M. Peterson, MD, PA Notice of Privacy Practices has been provided to me for my review. I understand that the purpose of this notice is to inform me of my rights in regard to my Protected Health Information and also the way in which Chris M. Peterson, MD, PA may use my Protected Health Information.

Preferred pharmacy

Required by Federal Government

Social History

FAMILY HISTORY (only include Father, Mother, Brother or Sister)

Please indicate which family member has a history of condition by checking.

Choose ONE Option

Option One

Option Two

Sign and Date

My signature below acknowledges that a copy of the privacy practices followed at CHRIS M. PETERSON, MD, PA is available to me upon request.