You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

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1 Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly. You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: apple 1212 Rockview Dr., Texas (Directions are enclosed) You will have the opportunity to discuss insurance copays, deductibles and/or coinsurance with the insurance specialist. Any copay, deductible and/or coinsurance will be collected before or at the time of service. If your insurance requires a referral, please contact your primary care physician s office to obtain one. Please mail/bring the following forms: apple Patient Information apple Release of Medical Records apple Payment Policy apple List of Medications apple Release of Medical Records for slides, if applicable apple Power of Attorney, if applicable apple Copy of drivers licence, insurance card(s) front and back If you are unable to mail your forms, you may bring them to your appointment. Please arrive for your appointment at least 15 minutes early to fill out Patients Privacy Act (HIPAA) forms. Please be sure to bring your insurance cards and a valid federal or state- issued picture ID to your first appointment. 300 W. Arbrook, Suite D (817) Office (817) Facsimile, TX 76049

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3 (Please Print and Use Black Ink!) PATIENT INFORMATION (Please Print and Use Black Ink) Patient Name: apple Male or apple Female Social Security #: - - Birthdate: / / Age: Race: Ethnicity: Language Spoken: Street Address (no P.O. Box): City: State: Zip: Home Telephone: Cell: Employer: Work #: Marital Status: PLEASE CIRCLE ONE: Single Married Widowed Divorced Spouse s Name: Spouse s Work #: Emergency Contact Not Living with You: Phone #: Relationship: Family Physician & Phone #: Referring Dermatologist: INSURANCE INFORMATION Primary Insurance: Insurance Phone #: Name of Policy Holder: DOB: SSN: Policy/ID#: Group #: Claims Address: Secondary Insurance: Insurance Phone # Name of Policy Holder: DOB: SSN: Policy/ID#: Group #: Claims Address: INSURANCE AUTHORIZATION I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare or insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. Signature: Date: 300 W. Arbrook, Suite D (817) Office, TX (682) Office

4 RELEASE OF MEDICAL RECORDS Patient Name Date of Birth Last 4 digits of SSN Name and complete mailing address of the person to receive your records is required to process this request. Please include a fax number to expedite your request. Send copy of records to: Send Copy of records from: I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non- health care provider, the released information may no longer be protected by federal and state privacy regulations. The following information is requested and may be released: ALL RECORDS Progress Notes Slides Pathology Reports Operative Reports Medications Other By checking ALL RECORDS, I hereby give my express consent to release all medical records regarding my treatment, including psychological treatment, drug abuse, alcohol use, human immunodeficiency virus (HIV) infection including acquired immunodeficiency syndrome (AIDS) or tests for HIV, or sexually transmitted diseases. ***Description of purpose of the use and/or disclosure PLEASE SPECIFY: I understand that this authorization will expire by law 180 days from the date of this authorization unless I otherwise specify. I further understand that I may revoke this authorization at any time by notifying Charles D. Kennard, M.D., P.A. in writing. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before receipt of the written revocation. I understand that copies of records are subject to a $25.00 minimum fee. Signature of Patient or Representative Date Daytime Phone Number, TX 76049

5 PAYMENT POLICY We will file your insurance claims for you, but we do require that you pay any copays, deductibles and/or coinsurance at the time of service. At this time we accept cash, checks, money orders, Visa, MasterCard and Discover for payment. Please read and initial each paragraph: Mohs micrographic surgery is different from any other surgeries performed when it comes to return appointments. If Dr. Kennard does not perform any type of repair which is called granulation, all return visits for bandaging changes, and/or wound checks will be billed as a nurse visit. If the wound is repaired, your return visit for suture removal is included in the cost of the surgery, and there will be no charge. It is your responsibility to notify our office of any changes in your personal information or insurance coverage prior to your next visit. If you have any questions about our payment policy please feel free to contact our office at (817) You may receive a copy of this payment policy upon request. Patient Signature Date Witness Signature Date, TX 76049

6 Medications Patient Name: DOB: Allergies: Local Pharmacy: Pharm Phone #: Medication Dosage (mg, g, etc) Please include ALL vitamins and over the counter medications you are currently taking., TX 76049

7 DIRECTIONS TO GRANBURY OFFICE: - KEEP THIS PAGE, do not mail back Directions from Ft. Worth: From I- 20: Take exit 429A to merge onto US- 377 S/Benbrook Blvd toward Continue to follow US- 377 S for 25.4 miles Turn right onto Portal Drive Destination will be on the right Directions from Stephenville: Take US- 377 N/E S Loop Continue to follow US- 377 N for 29.9 mi Turn left onto Portal Drive Destination will be on the right, TX 76049

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