New Patient Form

DERMATOLOGY OF MIAMI

SUNSET DRIVE / MIAMI LAKES

George D. Glinos, MD, FAAD
Yesenia Sebastia, APRN-BC
Alexandra Riguero, PA-C
Bethany Aguilar, MCMSc, PA-C

PATIENT INFORMATION

Name: *

Social Security No:

/ /

Address: *

Apt. No:

City / State: *

Zip: *

Telephone Home:

Cell: *

Work:

Patient's Email Address: *

Pharmacy Info:

Primary Physician:

Telephone:

Referred By:

Spouse Name:

Legal Guardian (If Applicable):

Phone Number:

Legal Guardian Date of Birth:

Emergency Contact: *

Telephone: *

Relationship: *

PATIENT EMPLOYER INFORMATION

Employer Name:

Telephone No:

Address:

City:

State:

Zip:

Patient Occupation:

PRIMARY INSURANCE - INFORMATION MUST BE COMPLETED

Insurance Company: *

Insured's Name: *

Relationship: *

Date of Birth: *

Insured's Phone Number:

SECONDARY INSURANCE

Insurance Company:

Insured's Name:

Relationship:

Date of Birth:

NOTE: Most HMO Insurance Companies allow 5 visits a year without an authorization from your Primary Care Physician.

PLEASE ANSWER THE FOLLOWING QUESTION:

I have or have not seen another dermatologist this year.

If you have, please list the doctor's name and the number of times seen:

If you have been seen by a dermatologist 5 or more times, you may need an authorization. Please discuss this with our Front Desk Staff.

INFORMATION AND ASSIGNMENT OF BENEFITS:

I authorize the release of any medical information necessary to process this claim. I hereby authorize George D. Glinos, MD to apply for benefits on my behalf for covered services rendered by him or by this order. I request that payment from my Insurance Company be made directly to George D. Glinos, MD (or to the party who accepts assignment). I Certify that the information I have reported with regard to my Insurance coverage is correct. If this information is incorrect, the office may bill me for the full amount for any date of service applicable. Any unpaid balances may be forwarded to a Collection Agency. At that time a $25.00 Processing Fee will be added to your invoice. This does not include the Collection Agency Fees. I permit a copy of this authorization to be used in place of the original. This authorization can be revoked at any time by myself or my Insurance Company.

FAMILY HISTORY

Psoriasis:

Eczema:

Asthma/Hay Fever:

Skin Cancers - Melanoma:

Basal Cell:

Squamous Cell:

Heart Disease:

Stroke:

Cancer:

Diabetes:

High Blood Pressure:

Kidney Disease:

Hepatitis:

Depression:

GENERAL RECORDS RELEASE AUTHORIZATION

Your Medical Records or Laboratory Results may be requested by your Primary Family or Specialist Physician to coordinate your care. I authorize George D. Glinos, MD and/or staff to send records to the requesting physician or lab.

Please list any family member or friend that may access your Health Information or speak with the Doctor or Staff in reference to you:

WRITTEN ACKNOWLEDGEMENT FORM - RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , have (1) received a copy of the Notice of the Privacy Practices or (2) has been offered a copy of the Notice of the Privacy Practices but declined to accept a copy.

APPOINTMENT CANCELLATION POLICY

DATE:

Effective September 1, 2023 all cancellations made with less than one full business days' notice may result in a cancellation fee of $50.00 If I fail to show for my scheduled General Medical appointment, I may be charged a no-show fee of $50.00.

I understand that two full business day cancellation notice is required for all Cosmetic and Surgical Appointments. All cancellations made with less than two full business days' notice may result in a cancellation fee of $100.00. If I fail to show my Cosmetic or Surgical appointment, I may be charged a no-show fee of $100.00 and forfeit any applicable deposit.

I understand that all patients are given a 15-minute grace period from their scheduled appointment. The practice cannot guarantee that patients who arrive 15 minutes past their scheduled appointment time will be seen and may need to be rescheduled.

I have read and fully understand my responsibilities regarding the office cancellation and late policy listed above.

I Certify by my signature below that I have read and understand the appointment charge agreement.

AUTHORIZATION & SIGNATURE

Sign here: *

Signature Preview:

Printed Name: *

Date: *

PROVIDER INFORMATION

Provider Name:

Provider Signature:

Date:

DERMATOLOGY OF MIAMI

PATIENT INFORMATION

PATIENT EMPLOYER INFORMATION

PRIMARY INSURANCE - INFORMATION MUST BE COMPLETED

SECONDARY INSURANCE

PLEASE ANSWER THE FOLLOWING QUESTION:

INFORMATION AND ASSIGNMENT OF BENEFITS:

GENERAL MEDICAL INFORMATION

FAMILY HISTORY

GENERAL RECORDS RELEASE AUTHORIZATION

WRITTEN ACKNOWLEDGEMENT FORM - RECEIPT OF NOTICE OF PRIVACY PRACTICES

APPOINTMENT CANCELLATION POLICY

AUTHORIZATION & SIGNATURE

PROVIDER INFORMATION

Average Rating: 4.87 / 5

New Patient Form

DERMATOLOGY OF MIAMI

PATIENT INFORMATION

PATIENT EMPLOYER INFORMATION

PRIMARY INSURANCE - INFORMATION MUST BE COMPLETED

SECONDARY INSURANCE

PLEASE ANSWER THE FOLLOWING QUESTION:

INFORMATION AND ASSIGNMENT OF BENEFITS:

GENERAL MEDICAL INFORMATION

FAMILY HISTORY

GENERAL RECORDS RELEASE AUTHORIZATION

WRITTEN ACKNOWLEDGEMENT FORM - RECEIPT OF NOTICE OF PRIVACY PRACTICES

APPOINTMENT CANCELLATION POLICY

AUTHORIZATION & SIGNATURE

PROVIDER INFORMATION

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