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Hecker
Dermatology Patient Information Print/Fax Form |
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Responsible Party Information |
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| Name (Last, First, MI) | Social Security | Birth date | Sex | |
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| Phone | Phone (Work) | Email Address | Marital Status | |
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| Mailing Address | City | State | Zip | |
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| Employer | City | State | Zip | |
How did you hear about our Office? _____________________________________________________________ |
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Patient Information (if other than responsible party) |
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| Name (Last, First, MI) | Social Security | Birth date | Sex | |
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| Phone | Phone (Work) | Email Address | Marital Status | |
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| Mailing Address | City | State | Zip | |
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| Employer | City | State | Zip | |
Insurance Information (please present your current insurance card(s) |
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| Insurance Company | Subscriber/Guarantor Name | Policy No. | Group No. | Relationship |
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| Second Insurance Company | Subscriber/Guarantor Name | Policy No. | Group No. | Relationship |
Please list all present medications and any known drug allergies: |
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Patient Release |
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| I certify the
information that I have provided is correct. I authorize the release of
medical information necessary to process insurance claims to insurance
companies or their agencies (including Medicare), for the purpose of
filing and payment of medical claims. I authorize payment of medical
benefits to the provider (Hecker Dermatology Group, PA). I ACKNOWLEDGE
THAT INTEREST OR A FEE AT THE PROVIDERS CURRENT RATE, MAY BE CHARGED on
all balances owing to the provider that are past due.
I permit a copy of this release to be used in place of the original. |
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| Signature of insured or authorized person, patient or parent if minor | Today's Date | |||