The Dermatologic Surgery Center of Washington, LLC

Skin Cancer Treatment Center, LLC

Maral Kibarian Skelsey, MD

5530 Wisconsin Ave., Suite # 820

Chevy Chase, MD 20815

Tel #: 301-652-8081 Fax #: 301-652-8627

Patient's Name: (LAST) (FIRST) (MI) Address: City: State: Zip Code: Referral Dr.: Sex (M/F): Status (S/M/D/W): Birthday: SSN Home Phone: Work Phone: Cell Phone: Email: Emergency Contact: Emergency Phone:

Primary Insurance Coverage

Company: Insured Name: Relationship: DOB: Co-Pay Amount: Policy/ID #: Group #: Employer:

Secondary Insurance Coverage

Company: Insured Name: Relationship: DOB: Co-Pay Amount: Policy/ID #: Group #: Employer:

Guarantor Name: Relationship to Patient: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email:

Patient's Authorization

I authorize The Dermatologic Surgery Center of Washington, LLC and Skin Cancer Treatment Center, LLC to apply for benefits on my behalf. I request payment from my insurance company be made directly to them as well. I certify that the information I have reported with regard to my insurance coverage is correct. I further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at any time in writing. I understand that nothing herein relieves me of the primary responsibility and obligation to pay for medical services provided, when a statement is rendered.

Signature of Subscriber or Beneficiary: Date: