Patient Information




To confirm return appointments, may we email or text you?

With my consent Greenwood Dermatology may text, call, leave a message or mail to my home any items that assist the practice in carrying out treatment payment and healthcare operations.

Greenwood Dermatology may call and/or text appointment reminders

Greenwood Dermatology may text or leave a message with any medical information on my voicemail

Emergency Contact Information

Parent, Spouse or Responsible Party (If different from patient)

Physician Information:

Were you referred by a physician

Insurance Information

Please sign so we may have your insurance authorization on file

I authorize any holder of medical and/or other information about me to be released to the above insurance company(s), and any information needed for this or a related insurance claim. I hereby assign to the physician all payments for medical services rendered to my dependents or myself. I understand that I will be billed and I am responsible for any amount that is not covered by my insurance.

Upload insurance card(s) and a photo ID

Payment Policy:

The doctor appreciates the confidence you have shown in choosing us to provide for your healthcare needs. The service you have elected to participate in implies a financial responsibility on your part. As a courtesy, we will bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill. The patient or legal guardian is responsible for all fees incurred for office medical services regardless of insurance coverage. This includes any amount the insurance does not cover for office visits and in the unlikely event of complications from treatment, the patient is responsible for fees charged by other physicians or hospitals. Any amount that insurance does not pay will be billed directly to you. Any co-payments that you are liable for with your policy, as well as any medications, charges for noncovered services, products you may purchase at the office, and cosmetic services are due at the time of the visit.

Electronic recording is prohibited within the office.

The Adult/Guardian who brings in the child will be responsible for all copayments and deductibles. We do not forward bills to other parties regardless of court rulings or divorce decrees.
If we receive payment fom the primary insurance, we will file a claim with your secondary. If we do not receive payment from your primary carrier, you will be billed for the entire amount.

It is ultimately the patient's responsibility to verify that the physician is in your network, and to obtain any referrals your insurance may require.

Payment is expected when services are rendered. Delinquent accounts are subject to a 2% finance charge per month.

If insurance does not pay your claim within 90 days, you will be responsible for the amount in full. It is your responsibility to make sure that these claims are paid in a timely manner.

Please be advised that not all of our physicians are enrolled as a Medicaid provider. We recommend verifying your coverage with your insurance company, as you may be financially responsible for any charges they do not cover.

I understand that should my account become past due, it may be placed with a collection agency. If it is, I am aware that I am responsible for all collection agency fees (33 1/3%) of my account balance), attorney fees and court costs.

No Show/ Late Cancellation: In order to provide timely care for all of our patients, we have a no show/ late cancellation fee. A twenty-four hour cancellation of your appointment must be given to avoid being assessed a $50.00 charge for a missed appointment. If you miss a scheduled surgery appointment, there will be a $100.00 fee. These fees are not covered by your insurance.

There will be a $25.00 charge for any returned checks.


1. How were you referred to us?

5. Do you have or have you ever had any of the following:




Do you smoke

High Blood Pressure

Heart Attack

Heart Murmur / Rheumatic Fever

Palpitation/Irreg. or fast heart beat

Heart disease, angina or chest pain

Artificial Pacemaker / Defibrillator



Thyroid trouble

Kidney or bladder problems

Stomach or bowel Problems

Hepatitis, jaundice, liver disease

Convulsions or epilepsy




Hepatitis B Exposure

AIDS or HIV Exposure


Blood Transfusion

Do you drink alcohol

If yes, how many

7. Do you have any medication allergies?

9. Any personal history of skin cancer

10. Any personal history of other skin disease

11. Any family history of skin cancer

12. Any family history of skin disease

13. Do you have any scarring tendencies after surgery

14. For Women Only.

Are you pregnant

Completed By

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Greenwood Dermatology to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Greenwood's Notice of Privacy Practices provides a more complete description of such uses and disclosures.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Greenwood Dermatology reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Greenwood Dermatology, 92 South Park Blvd, Greenwood IN 46143 Attn: Office Manager.

With this consent, Greenwood Dermatology may call my home or alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.

With this consent, Greenwood Dermatology may mail to my home or alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, lab results, and patient statements.

With this consent, Greenwood Dermatology may e-mail to my home or alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

You may have the following right with respect to your PHI:
The right to request that Greenwood Dermatology restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. The right to reasonable request to receive confidential communication of PHI by alternative means or at alternative locations. The right to inspect and copy your PHI. The right to amend your PHI. The right to obtain a paper copy of this notice from us upon request. The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

If you have paid for services "out of pocket", in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure. You must submit your request in writing to the office manager.

Do you give our office permission to discuss your medical information with a family member or care giver:


Please sign electronically below.

Your browser does not support the signature

Click submit and you hereby give consent to sign this document electronically.

Sending data