Get Leavitt Medical Dba Advanced Dermatology

Filling out the Leavitt Medical Dba Advanced Dermatology form online is a straightforward process, designed to collect essential patient information efficiently. This guide provides step-by-step instructions to help you accurately complete each section of the form, ensuring a seamless experience.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and launch it in your chosen editing tool.
2. Begin by entering your patient information. Fill in your name in the format of Last name, First name, Middle name. Provide your medical record number (MRN) if available.
3. Complete your local address, including city, state, and ZIP code. Then, enter your home phone number and marital status.
4. Provide your Social Security number (SSN), day phone, and email address. Indicate your student status, smoking status (yes/no), and whether you are a veteran (yes/no). Add your birthdate and sex.
5. If applicable, enter the secondary or billing address for additional correspondence. Include all relevant details.
6. Identify your referring physician and provide their city, state, and ZIP code. Next, list your primary care provider, including their home phone number.
7. Fill in your employment information by detailing your primary employer's name, address, city, state, ZIP code, and work phone. If you have a secondary employer, provide the same information for them as well.
8. If someone else is responsible for the information provided, enter their details in the Responsible Party Information section, including their name, SSN, local address, marital status, home phone, relationship to the patient, and employment status.
9. Proceed to Primary Insurance. Enter the name of the insurance company, policy number, name of the insured, group number, and address of the insurance company. Also, indicate the copay amount and deductible, along with the relationship to the patient.
10. If there is a secondary insurance policy, provide the same information as listed in the primary insurance section.
11. Finally, the patient or guardian must sign and date the form, indicating their consent and accuracy of the information provided.

Complete your documents online today for a smooth and convenient process.