Welcome to Upstate Dermatology, PC. We look forward to providing you with quality dermatological care.

Note: To expedite the new patient registration process, please arrive at least 20 minutes prior to your scheduled appointment time. Prior to your visit, please take a few minutes to complete the enclosed documents and bring them with you on the day of your appointment: Please complete the following:

• Patient Information • Medical History • General and Financial Consent • Current Medications Listing • HIPAA Authorization • Be sure to bring your insurance card(s) and Photo ID.

Plan to arrive on time for your appointment – late arrivals will be given the next appointment time available either that day or a future date. Additional documents that may apply to you:

• Minor Consent Form (if you are a minor, please have your guardian review and sign). Please note: For the first appointment, a minor must be accompanied by the parent or legal guardian.

• Medicare Authorization Form / Assignment of Benefits / E-prescribing Consent • Referral (If your plan requires a referral from your PCP, please confirm that

your valid referral has been received by our office prior to your visit, or bring it with you. Patients who have not obtained a valid referral in time for their appointment will be asked to sign a waiver to pay for their visit in full, or reschedule the appointment until the referral is obtained).

Copayments and Deductible Plans: Copayments are due at the time services are rendered. Deductible Plan subscribers will be required to pay a deposit towards their deductible, at the time of their appointment.

No Show Fee: Please notify us 24 hours in advance, if you are unable to keep your scheduled appointment, otherwise a $50 no show fee will be billed to your account. Questions / Changes to your account or appointment, please contact us at: Schenectady: (518) 374-7222 at 461 Clinton Street Extension, Schenectady Chatham: (518) 392-6742 at 113 Hudson Avenue, Chatham Clifton Park: (518) 631-2933 at 1770 Route 9 North, Clifton Park Schodack/East Greenbush: (518) 479-4156 at 1547 Columbia Tpke., Castleton

Privacy Notice

I acknowledge that I was provided with the Notice of Privacy Practices of the Medical Practice named at the top of this page.

Print Name of Patient:

Signature of Patient:

Date:

Patient’s Date of Birth:

Personal Representative (if applicable)

Print Name of Personal Representative:

Signature of Personal Representative:

Relationship to Patient:

Date:

I authorize the person/persons listed below to obtain medical information on me:

Name: DOB: Relationship:

Name: DOB: Relationship: Comments:

Signature of Practice Employee Date

Any questions regarding our privacy notice can be directed to our privacy official, Brian Brill.