Patient Registration Form


Patient Registration Form























  • Emergency Info

  • PRIMARY INSURANCE

  • GUARANTOR INFORMATION








  • SECONDARY INSURANCE

  • I hereby authorize and direct my physician, having treated me, to release to government agencies, insurance carriers, or others who are financially liable for my hospitalization and medical care, all information needed to substantiate payment for such care and treatment.

    I request that payment of authorized benefits be made either to me or on my behalf to Dr. Eyal Levit for my service(s) provided by Advanced Dermatology Laser & Cosmetic Surgery if insurance will deny payment for the service(s).

    PATIENT AGREES TO PAY ADVANCED DERMATOLOGY LASER & COSMETIC SURGERY ALL DENIED, UNPAID OR RECOVERED AMOUNTS IF THE LISTED INSURANCE INFORMATION IS DETERMINED TO BE INACCURATE OR INCOMPLETE, INCLUDING, BUT NOT LIMITED TO, BY STATING AN INCORRECT PRIMARY INSURER.

    I agree that Advanced Dermatology Laser and Cosmetic Surgery may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payors for treatment purposes.


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