Alan M. Gardner, M.D. - Atlanta, GA - Physician & Surgeon - MD

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Patient Information

* FAX TO 770-850-9712 OR BRING TO OFFICE

VISIT INFORMATION:

PATIENT NAME:_____________________________________ DATE:____________

ADDRESS:____________________________________________________________

SOCIAL SECURITY NUMBER:____-____-______  MARITAL STATUS: __________

HOME PHONE:__________________    WORK PHONE:_______________________

EMPLOYMENT: Company Name___________________________________________
                         Address_________________________________________________

REASON FOR VISIT:____________________________________________________

ACCOUNT HOLDER/GUARANTOR INFORMATION:
INDIVIDUAL TO RECEIVE BILLS (IF SELF, SKIP THIS SECTION):

FULL NAME:____________________________________________________________

RELATIONSHIP TO PATIENT:__________________       DATE OF BIRTH:_________

ADDRESS:_____________________________________________________________

SOCIAL SECURITY NUMBER:____-____-______

HOME PHONE:_______________    WORK PHONE:__________________

EMPLOYMENT: Company Name___________________________________________
                         Address_________________________________________________

PLEASE LIST THE NAMES OF ANY FAMILY MEMBERS THAT RESIDE IN YOUR HOUSEHOLD:
______________________________________________________________
______________________________________________________________
______________________________________________________________

MEDICAL INSURANCE INFORMATION
(please submit your card(s) to be copied)

INSURANCE
COMPANY NAME

CARD/POLICY
HOLDER NAME

POLICY #

SUBSCRIBER'S
SS#

TYPE OF COVERAGE
PRIMARY-SECONDARY-TERTIARY







PLEASE LIST NAME OF THE CARD HOLDER'S EMPLOYER:___________________

PATIENT'S RELATIONSHIP TO CARD/POLICY HOLDER
OR SUBSCRIBER TO INSURANCE_________________________________________

       INSURANCE COMPANY NAME   CARD-POLICY HOLDER NAME     POLICY NUMBER   SUBSCRIBER'S SOCIAL SECURITY NUMBER

(PAST MEDICAL HISTORY (Yes or No, please explain):)

INFECTIOUS DISEASES__________

ALLERGIC DISEASES___________

OPERATIONS, INJURIES_________

SKIN DISEASE_________________

TB OR OTHER LUNG DISEASE_____________

CARDIAC DISEASE, SYMPTOMS, HYPERTENSION_____________

GASTROINTESTINAL ULCER, JAUNDICE, HEPATITIS_____________

URINARY DISEASE_____________

NEUROLOGICAL OR PSYCHIATRIC_____________

BONES AND JOINTS_____________

ENDOCRINE_____________

ANEMIA, BLEEDING OR BRUISING_____________

VENERAL DISEASE_____________

LIST CURRENT MEDICATIONS:__________________________________

MEDICATION ALLERGIES_______________________________________

(FAMILY HISTORY:)
SKIN DISEASE_____ALLERGY_____DIABETES_____CANCER_____OTHER_____
EXPLAIN:_____________________________________________________________

______________________________________________________________

PAYMENT POLICY

Considerable care has been taken *in setting our fees. We want to assure you that our charges accurately reflect the complexity of care rendered and the skill and expertise required for your care. Our fees are comparable with fees of other dermatologists in this area.

Our policy requires payment at the time of service for office visits and procedures. To assist you in filing your own insurance claim, we will provide you with and itemized statement. You can send the itemized statement to your insurance company for reimbursement.

Our agreement is with YOU and NOT your 'insurance company. You (and perhaps your employer) have chosen your *insurance coverage. Although we will assist you in submitting your claim to your carrier you are ultimately financially responsible for the services you receive. Payment to our office is neither contingent nor dependent upon your 'insurance company.

HMO and PPO members: If you are a member of an HMO or PPO in which we participate, your deductible or co-payment is required at the time of service. YOU are responsible for seeing that we have a current referral on file, if your insurance company requires one. If we do not have this referral at the time of your visit, your insurance could hold you responsible for all charges. You may be sent back to see your Primary Care Physician to obtain a referral prior to being treated.

COSMETIC SERVICES AND PRODUCTS are not covered by insurance and will not be filed with your insurance company. Payment for all cosmetic services are payable at the time of service. Some cosmetic procedures will require a deposit to be made at the time the procedure is scheduled.

BROKEN APPOINTMENTS: We require a 24-hour notice to cancel an appointment. This allows patients with emergencies the opportunity to be worked into that time slat. Appointments broken without a 24-hour notice are subject to a charge. The type of service that was scheduled will determine this charge. Insurance will not cover this charge.

OUTSIDE LABORATORY SERVICES: Some procedures require specimen to be sent to an outside laboratory. This is a separate facility and you may receive a separate statement from them. If your insurance requires a specific laboratory to be used, please inform someone at the time of your procedure.

For your convenience, we are pleased to accept MasterCard, VISA, American Express and Discover. There will be a $20.00 charge for all returned checks.

A collection agency may take over a delinquent account. If any account is placed with a collection agency, the patient will be responsible for all costs of collection. Timely payment will prevent consequences to your credit rating.

If you have any questions about our financial policy or your insurance reimbursement please feel free to discuss them with our business office staff.

I HAVE READ AND UNDERSTAND MY FINANCIAL RESPONSIBILITIES UNDER THIS POLICY

Patient Signature_______________ Date________________

Alan M. Gardner, M.D.
2550 Windy Hill Rd., Suite 220 • Marietta, GA 30067
(770) 952-2100 • Fax: (770) 850-9712

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