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Patient Information

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Responsible Party
(If different than patient)

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Insurance Information

PRIMARY INSURANCE COMPANY
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SECONDARY INSURANCE COMPANY
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Policies and Consents

**Medical Photography Consent: Medical photographs may be taken and stored in patients’ electronic medical chart. **HIPAA Consent Policy: With my consent, Ozark Dermatology Clinic (ODC) may use and disclose my protected health information to carry out treatment, payment and healthcare operations (TPO). I understand that I have the right to review ODC's Notice of Privacy Practices and have been given the opportunity to do so. With my consent, ODC may call my house or other designated locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, lab results and insurance information among others.

Signature Required
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My private information can be released to the following persons:
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Payment and Insurance Policy: To avoid a $35 fee, a 24 hour cancellation notice is required.
Payment is due upon completion of today's office visit. If you have insurance, we will be happy to process your claim, but we request that you pay your estimated portion at the time of service. This includes any co-pays, percentages and deductibles. We require that all insurance payments are hereby assigned to Ozark Dermatology Clinic for services rendered to the patient or dependent. Charges denied due to insurance policy limitations will be transferred to the patient or guarantor. Payment for any treatment deemed by insurance companies to be cosmetic or not medically necessary is the responsibility of the patient. FAILURE TO KEEP SURGERY APPOINTMENTS WILL RESULT IN TERMINATION OF CARE FROM OZARK DERMATOLOGY CLINIC.

Signature Required
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Skin Related Illnesses

Skin Cancer:

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Past Medical History: Have you had ANY problems in the past with the medical systems listed below?
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CURRENT MEDICATIONS
***IF YOU HAVE A PAPER LIST OF YOUR CURRENT MEDICATIONS, PLEASE PROVIDE TO THE RECEPTIONIST AND SHE WILL MAKE A COPY***

Current Prescriptions
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FAMILY MEDICAL HISTORY: Please check the following that have occurred in your family.

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Social History:

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Note* If you do not receive the "thank you" message once you click the SEND button then please fill out the form and try again. It may take a few moments for you to see the thank you message, this is normal.