BLUEGRASS DERMATOLOGY AND SKIN SURGERY CENTER, PSC
Registration Form
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Required fields are bold and marked with *
Last Name*
First Name*
Middle Name
Date of Birth*
SSN - -
Sex
Ethnic Background*
Preferred Language*
Home phone* () -
Work phone () - x
Cell phone () -
Home Address (Primary)*
City*
State*
Zip code*
Occupation*
Employer
Email
(List only if you wish to be contacted via email)
Person to notify in case of an emergency
Name*
Phone no.* () - x
How did you hear about us?
Referring Physician
Friend
Phone Book
Other
Primary Physician
Primary Physician's phone no. () - x
Referring Physician
Referring Physician's phone no. () - x
Bluegrass Dermatology utilizes an automatic electronic system for prescriptions. Please fill in the following info:
Primary Pharmacy Name
Phone no. () - x
Primary Pharmacy Address
City
State
Zip code
Uncheck to skip Insurance Information for No Insurance / Private Pay
Insurance Policy:
Memberís Name (exactly as it appears on the card):*
Member's Date of Birth
Memberís ID:
Group #:
Address
(send claims to - back of card)
Parent or Responsible Party (if different from patient):
*Patients 18 yrs and UNDER must have Responsible Party info
Last Name
First Name
Middle Name
Home Address: (Primary)
City
State
Zip code
Home phone () -
Work phone () - x
Cell phone () - x
SSN - -
Sex
Date of birth
Employer

I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I alsoauthorize payment of medical benefits to the physician. I understand that I am responsible for any charges deemed not medically necessary by my insurance company or otherwise not covered by my insurance company, including, but not limited to co-pays, deductibles and co-insurance payments.

In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan with which we participate. For those patients, applicable co-payments and deductibles will be collected. We accept payment in the form of CASH, CHECK, VISA, MASTERCARD, DEBIT CARDS, MONEY ORDERS, and CASHIERS CHECKS. We also participate with Care Credit Financing. All balances due that do not get paid within the first 30 days are subject to finances which will accrueinterest monthly.