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PATIENT INFORMATION

  
*Patient's First Name Please enter a First Name.
*Patient's Last Name Please enter a Last Name.Please enter your street address.
*Date of Birth / Please Enter a Month. / Please enter a day. Please enter a year.
*Street Address Please enter a street address.
*City / State Please enter your city. /
*Zip Code Please enter a 5-digit zip code.Please us a 5-digit zip c
Cell Phone Number
*Home Phone Number Please enter a phone number.
I give the staff at Artemis permission to contact me at this home phone number regarding your services
Work Phone Number
Email Address Please enter an email address.Please enter a valid email address.

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PRIMARY INSURANCE INFORMATION

  
Insurance Company Name
CoPay Amount
Group Name or Number
ID Number
Claims Address
City / State
Zip Code
Phone Number
   
Policy Holder's Name
Date of Birth
Address
City / State
Zip Code
Phone Number
Policy Holder's Employer
Employer's Group Plan
No Please make a selection.

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Secondary INSURANCE INFORMATION

  
Insurance Company Name
CoPay Amount
Group Name or Number
ID Number
Claims Address
City / State
Zip Code
Phone Number
   
Policy Holder's Name
Date of Birth
Address
City / State
Zip Code
Phone Number
Policy Holder's Employer
Employer's Group Plan
No Please make a selection.

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Additional INFORMATION

  
*Emergency Contact Please enter emergency contact.
*Relationship Please enter the relationship.
*Phone Number Please enter a phone number.
Work Phone Number
Cell Phone Number
Referring Physician
*Family or Primary Care
Physician		 Please enter family physician.
Pharmacy Name
Pharmacy Address
Pharmacy Phone Number
Who has access to your medical records? - This can be revoked at any time by contacting us.
   



ASSIGNMENT OF BENEFITS & INFORMATION RELEASE:

I hereby assign all medical and/or surgical benefits, to which I am entitled to Artemis Laser & Vein Center. This assignment remains in effect until revoked by me in writing. A facsimile or photocopy of this assignment is to be considered valid as an original. I hereby authorize said assignee to release all information necessary to secure payment. I consent to the release of information by Artemis Laser & Vein Center and my health insurance and/or payor to Artemis Laser & Vein Center, and its employees/representatives to facilitate peer review and of my treatment including utilization and quality management. I understand that Artemis Laser & Vein Center will maintain the confidentiality of this information at all times.

I understand that I am financially responsible for all charges whether or not paid by insurance. I understand that my medical insurance is a contract between myself and the insurance company and/or my employer. Artemis Laser & Vein Center is not a party to said contract. I understand that I am responsible for legal and/or collection fees necessary to settle my account, should it become delinquent.

CLICK HERE to read the HIPPA Notification of your privacy rights.

Please Click to Agree you have read the HIPPA notification.Check here to acknowledge my receipt of the HIPPA notification form.

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Artemis