Patient information/consent for accutane treatment

2963 Marne Highway, Mount Laurel, NJ 08054
● 856.638.1990 ● Fax 856.583.0359
● www.bruneaufamilycare.com
Patient Information Sheet
Last Name: _________________ First Name: _______________ MI:____________ Address: _________________________________ Apt. #_________________________ City: _________________________ State: _________ Zip Code:_____________________ Home Phone:_________________ Work: _______________ Emergency:_______________ Cell Phone # ___________________E-mail Address: _________________________________ EmployerName:_____________________________Occupation__________________________ Marital Status: Married Single Divorced Separated Widowed Other SS#: ____________ Patient Date of Birth; ________________ Sex: M F________________ Ethnicity: Hispanic or Latino__ Not Hispanic or Latino__ Unknown__ Race: American Indian or Alaska Native__ Asian__ Black or African American__ Native Hawaiian or Other Pacific Islander__ White__ Other Race__ Referred by:_________________________________________________________

Primary Insurance Information
Insurance Plan Name: Effective Beginning Date:_____________
Subscriber Name: Relationship to insured:_______________
DOB:_____________________________
Address:_________________________City:___________________State:_____Zip:__________
SS#___________________Sex:_M__F__ _Employer:__________________________________
Group Name:________________________Group #: ___________Policy #:_________________
CoPay Amt:______
Secondary Insurance Information

Insurance Plan Name:__________________________Effective Beginning Date:_____________
Subscriber Name: ________________________Relationship to insured:____________________
DOB:______________________ Employer:_________________________________________
Address:________________________City:____________________State:______Zip:_________
SS#_____________________Sex: M F _________________________________________
Group Name: ________________________Group #:___________Policy #:_________________
CoPay Amt:__________
Name: ________________________ SS#:__________________ DOB: __________________
Please read and sign authorization below: 1. I hereby authorize direct payment of medical benefits to Bruneau Family Care, P.C. for services rendered. I understand that I am financially responsible for any balance not covered by my insurance company. I certify that the information I have given in applying for payment is correct and I authorize release of all records upon request. A photocopy of these assignments shall be valid as the original. 2. I hereby authorize Bruneau Family Care, P.C. to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. 3. I hereby authorize any doctor to release necessary medical records that are requested by the 4. Co-payments are due at the time of service. 5. Any checks that are returned by your bank for any reason will result in additional fee of $25.00 which will be added to your balance. 6. Please note that if for any reason, you are not able to make your appointment, we require notification at least 24 hours in advance. If you are not able to make your appointment for any
reason and do not notify us, you will be charged a $20.00 fee regardless of your required co-
payment.
7. Due to billing rules established by insurance companies, Medical problems discussed during your yearly physical may result in collection of you copay or deductible. 8. All forms that need to be completed will be subject to a fee of at least $10.00 unless done at time
of visit. Comprehensive forms/letters may require additional fees. Payment is due at request of service. 9. All routine laboratory and radiology test results may take up to two weeks to get results, unless 10. Insurances requiring a referral must notify the office four days prior to your appointment, unless 11. Please be advised in the event you are 20 minutes late for your appointment you may be asked to 12. Please allow 24 hours for prescriptions to be refilled. 13. Due to the volume of emails the physicians receive, do not email the physicians for appointments, referrals, lab slips or prescription refills Name (print):________________________________ Signature ___________________________________ Date: _____________________ If relative, state relationship:_________________________________________________

Source: http://www.bruneaufamilycare.com/images/REGISTRATION_FORM_2-17-12.pdf