Patient Information Patient

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					Patient Information:

Social Security #: ______________________________________
Patient Name (Last, First, Middle): ___________________________________________________________________________
Mailing Address: __________________________________________________________________________________________
City: ________________________________________ State: ______________ Zip code:_______________________________
Phone #: (_____) ___________________ Cell #: (_____) ____________________ Work #: (_____) _______________________
Birthday: _____/_____/_____ Age: _______ Sex: _______ Race: __________________ Marital Status: __________________
Employed ____________ Retired ____________ Full Time Student ____________ Part Time Student ____________
Employer Name: ___________________________________________ Employer Phone #: (_____) _______________________
Person Responsible For Account: _________________________________ Relationship To Patient: _____________________
Mailing Address If Different Than Patient: _____________________________________________________________________
City: ________________________________________________ State: ____________ Zip code: _______________________
Spouse’s Name: __________________________ Employer: _____________________ Phone#: (_____)___________________
Person To Notify In Case Of Emergency: _______________________________________ Phone #: (_____) __________________
Pharmacy Name: __________________________________________ Pharmacy Phone # :(_____) _______________________
Pharmacy Address: _______________________________________________________________________________________
 Have you arranged for a Living Will? (advanced Directives) □ Yes □ No               Have you appointed a durable power of attorney? □ Yes □ No

Insurance Policy Information:

*Primary Insurance Company: _____________________________________________________ Co-Pay: $ __________________
  Policy Holder’s Name: __________________________________________________ Date Of Birth: ______/_______/_________
  Contract #: _______________________________________________ Group#: ________________________________________
  Relationship To Patient: ____________________________________________________________________________________
*Secondary Insurance Company: ______________________________________________________________________________
  Policy Holder’s Name: __________________________________________________Date Of Birth: _____/_______/__________
  Contract #: ________________________________________________Group#: _______________________________________
  Relationship To Patient: ____________________________________________________________________________________
*Third Insurance Company: __________________________________________________________________________________
  Policy Holder’s Name: __________________________________________________Date Of Birth: _____/_______/__________
  Contract #: ________________________________________________Group#: _______________________________________
  Relationship To Patient: ____________________________________________________________________________________

CONSENT FOR TREATMENT – I consent to necessary treatment, including drugs, medicine, performance of operations and conduct of
 X-ray, and/or other studies that may be used by the attending physician, her nurse, and/or staff.
AUTHORIZATION FOR RELEASE OF INFORMATION – I authorize Martin Bentley Dermatology & Skin Wellness to furnish any medical information
requested by insurance companies with whom I have coverage, any public agency which may be assisting in payment of my care, or my employer who is
providing payment of my medical bills due to an on the job injury.
ASSIGNMENT OF BENEFITS – I hereby authorize payment directly to Martin Bentley Dermatology & Skin Wellness of benefits otherwise payable to me,
including major medical insurance and payment of surgical or medical benefits, but not to exceed the Martin Bentley Dermatology & Skin Wellness charges for
these services. I understand that I am financially responsible to Martin Bentley Dermatology for charges not covered by this assignment. I authorize the
refund of overpaid insurance benefits where my coverage’s are subject to coordination of benefits.
GUARANTEE OF ACCOUNT – For services furnished by Martin Bentley Dermatology & Skin Wellness, I hereby guarantee the payment of all accounts for
services rendered. For payment of said accounts for services I hereby waive all claims of exemption under the State of Alabama and agree to pay, if
necessary, all costs of collection, including attorney’s fee.

_________________________________________________________                                                  ____________________________
                       SIGNATURE                                                                                       DATE

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