Grafton Dermatology & Cosmetic Surgery

Medicare Patient Registration

If you do not have an answer type in "none".

Date:

Patient Name: Sex:

Mailing Address:

City:

State:

Zip:

DOB:: Age: Home Phone:

SS#: Marital Status:

Referring Physician:

In Case of Emergency, we should notify:

Primary Physician: Phone:

Medicare ID:

This office is required to keep your signature on file authorizing us to file claims to Medicare for you and to release information to the payer if they require it for the proper consideration of a claim. Please read and sign the following statement:

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare Claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations per taining to Medicare assignment of benefits apply.

Electronic Signature: Date:

Do you have a Supplement Insurance Policy?

If Yes, Name of Supplement Insurance:

Policy Number:

Is the Supplement Insurance under your spouse name?:

If yes, Spouse Name: Date of Birth:

I request authorized Supplement Insurance Benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to the above insurance carrier any information needed to determine these benefits or the benefits payable for related services.

Electronic Signature: Date:

Please present your insurance cards and photo ID to the receptionist. The receptionist will make a copy and return them to you promptly.