To expedite the admissions process, please complete the following steps to pre-register for your appointment. You will be able to fill out our online form, print out your completed forms for your records and submit the files to us securely. We also have an option that allows you to just print the forms and fill them out by hand. Verification of identification, insurance and medical history will be conducted prior to your appointment. We look forward to meeting you.
Step 2 – Online Medical History Form (to follow step 1 form)
If you prefer printing and filling out the forms, you can open and print these pdf documents. Requires Adobe Acrobat Reader
|PATIENT INFORMATION||MEDICAL HISTORY|
|Download PDF||Download PDF|
NOTICE TO MANAGED HEALTH CARE PARTICIPANTS
As a Managed Health Care patient it is YOUR RESPONSIBILITY to identify yourself as a PPO HMO or POS patient to our secretary EACH TIME you visit our office.If your POS or HMO plan required for you to obtain pre-authorization from your primary care physician or patient advocate,please provide our office with this information prior to your visit with the doctor, in order to obtain the highest level of benefits. If you fail to obtain prior authorization as directed by your plan you will be responsible for payment at the time services are rendered.
I hereby authorize payment of insurance benefits to be paid directly to Derm Surgery Associates for any services furnished to me. I authorize Derm Surgery Associates to release information to Health Care Financing Administration and its agents, Medicare Champus, or any commercial insurance carrier covered by insurance or prepayment programs.