PATIENT INFORMATION
DERMATOLOGY GROUP OF ARKANSAS
9601 Baptist Health Drive Medical Towers I, Suite 690 Little Rock, AR 72205
Renie E. Bressinck, M.D. • Ray K. Parker, M.D. •Daniel F. Smith, M.D.•
M. Francine Bruyneel, M.D. • Hayden H. Franks, M.D. • Lindsay Enns, M.D.
PLEASE COMPLETE ALL INFORMATION REQUESTED BELOW
Today’s Date:
Patient Name: DOB:
Address: SS#:
City: State: Zip:
Home phone: Cell phone: Email:
Employer: Work phone:
Age: Sex: Marital Status: Married Single Widowed Divorced Separated
Ethnicity: Hispanic or Latino Non-Hispanic or Latino Language: Race:
Family/PCP Doctor: Address: Phone:
Referred By: Address: Phone:
Has your doctor forwarded any information to us Have you seen any of our doctors as a patient in this office before today?
Reason for your visit
Emergency contact person Phone
Alternate Emergency contact (Not living with you) Phone
Drug Allergies

 

PRIMARY INSURANCE
SECONDARY INSURANCE
Medicare # Medicare/Medipak #
Insurance Co. Name Insurance Co. Name
Group # Group #
ID# ID#
Name /Policyholder # Name /Policyholder #
DOB SS# DOB SS#
       
    COMPLETE THIS SECTION ONLY IF PATIENT IS A MINOR  
       
Parent/Legal Guardian Parent/Legal Guardian
Address Address
#1 Phone SS# #1 Phone SS#
Employer Employer
Address Phone Address Phone

 

AUTHORIZATION: I / We hereby state that the above information is true and correct to the best of my/our knowledge. I / We authorize Dermatology Group of Arkansas, PA to release any information acquired in the course of my treatment to my insurance company, employer, Physicians, institutions or third party payors, as required for certain claims filed. Patient/Guardian Initials
ASSIGNMENT OF BENEFITS STATEMENT: I / We authorize direct payment to be made to Dermatology Group of Arkansas, PA for any and all medical or surgical services rendered. I understand if any services or changes are not covered by my insurance carrier or my eligibility cannot be verified, I am responsible for all charges incurred. Patient/Guardian Initials
ACKNOWLEDGMENT OF OFFICE POLICIES (NO-SHOW AND CANCELLATIONS): I hereby acknowledge receipt of the Office Policies including No-Show and Cancellation Policies given to me by Dermatology Group of Arkansas, PA. Patient/Guardian Initials
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE: I hereby acknowledge receipt of the Notice of Privacy Practices (attached) given to me by Dermatology Group of Arkansas, PA. Patient/Guardian Initials
PHONE NUMBER TO CALL WITH ANY REPORTS OR LAB RESULTS:
You have my permission to leave a message at the above number
You have my permission to discuss my medical care with
Do not discuss my medical care with anyone but me
Please provide your pharmacy name and address for us to call in your prescriptions:
PRIMARY PHARMACY: ADDRESS: CITY:

Signature of Patient / Parent / Guardian / Insured

Printed Name

Date
 
GA 002