Get Patient Information Form - Catskill Dermatology

Filling out the Patient Information Form for Catskill Dermatology online is a straightforward process that ensures accurate representation of your medical history. This guide provides clear, step-by-step instructions to assist you in completing the form effectively.

Follow the steps to complete the form online.

1. Use the ‘Get Form’ button to access the Patient Information Form and open it in your preferred application.
2. Begin by entering the patient's name in the designated field. Make sure to input their full name accurately.
3. Next, fill in the date of birth and specify the patient's sex. Ensure that the date format is correct.
4. Provide the patient’s social security number in the corresponding section. Keep this information private and secure.
5. Select the marital status from the options provided. This information is important for record-keeping.
6. Enter the permanent address, including street or P.O. box, city, state, and zip code.
7. If applicable, fill in the local or seasonal address following the same format as the permanent address.
8. Input the home phone, local phone, and cell phone numbers. It's important to have accurate contact information.
9. Complete the employer name and work phone number section if applicable.
10. Indicate whether you are the insurance policyholder and, if not, provide the policyholder's name, date of birth, and relationship to the patient.
11. Fill out the spouse or parent information if relevant. Include their name, date of birth, and relationship to the patient.
12. Provide the primary physician's name, phone number, and address if a referral is required for specialists.
13. Input the primary and secondary insurance information as well as prescription insurance details. Ensure that the insurer's policies are properly documented.
14. Review the authorization statements regarding treatment and insurance information. Check the applicable boxes and provide your signature and date to confirm.
15. Answer the medical history questions clearly, including any medications you are taking and any allergies.
16. Lastly, indicate your preference regarding the consent to discuss your medical condition with others and list those individuals if desired.
17. After completing all fields, review the form for accuracy. You can then save your changes, download, print, or share the completed form as needed.

Complete your Patient Information Form online today to ensure a smooth visit to Catskill Dermatology.