PATIENT INFORMATION PRE-REGISTRATION FORM Items marked with asterisk (*) are required Referring Physician Select Your Physician * -- Select Doctor -- No Preference Jon Stern, M.D. Adrienne Glaich, M.D. Leonard H. Goldberg, M.D., FRCP Lucile White, M.D. Arash Kimyai-Asadi, M.D. Ming H. Jih, M.D. Sindy Pang, M.D. CONTACT INFORMATION   Patient First Name* Patient Middle Name Patient Last Name* Age        Social Security   Date of Birth* Marital Status Single   Married   Divorced   Widow/Widower Sex Male   Female   Address City / State   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code Home Phone* Daytime Phone Cell Phone Can we contact you via email?* Yes No Email Address*     EMPLOYERS INFORMATION   PRIMARY CARE PHYSICIAN   Company Position  Address  City / State       AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip    Primary Care Physician     INSURANCE INFORMATION           Primary Insurance Company Phone Address City / State   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip   Insured Name Date of Birth Social Security Policy Number Group Number     SECONDARY INSURANCE COMPANY   Secondary Insurance Company Phone Address City / State   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip   Insured Name Date of Birth Social Security Policy Number Group Number     EMERGENCY CONTACT INFORMATION   Emergency Contact                           Home Phone                                       Work Phone   Cell Phone Relationship

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NOTICE TO MANAGED HEALTH CARE PARTICIPANTS

As a Managed Health Care patient it is YOUR RESPONSIBILITY to identify yourself as a PPO HMO or POS patient to our secretary EACH TIME you visit our office.If your POS or HMO plan required for you to obtain pre-authorization from your primary care physician or patient advocate,please provide our office with this information prior to your visit with the doctor, in order to obtain the highest level of benefits. If you fail to obtain prior authorization as directed by your plan you will be responsible for payment at the time services are rendered.

I hereby authorize payment of insurance benefits to be paid directly to DermSurgery Associates / DSA Surgery Center for any services furnished to me. I authorize DermSurgery Associates to release information to Health Care Financing Administration and its agents, Medicare Champus, or any commercial insurance carrier covered by insurance or prepayment programs.