New Patient Form

* REQUIRED FIELD. Please enter “NA” for any required field that you are not sure about.

Patient Information:

Insurance Information:

Authorized person to disclose health information to:

Responsible Party Information (if different from patient)

Appointment Authorization

Should a parent or guardian not be able to accompany the patient to his/her appointment, please list all persons authorized to bring your child/children to their Dermatology appointment at our office. At your child’s appointment, an update will be required; therefore, the person bringing your child will be responsible for providing a photo ID, information about any medical changes, current medications and concerns.

The person accompanying your child will have to be 18 years old or older in order to complete the medical update


ASSIGNMENT OF BENEFITS

I authorize all insurance benefits be paid to the provider rendering services on behalf of Texas Dermatology and Laser Specialist, I understand for payment for professional services, including co-payments, deductibles and fees for cosmetic services, are due at time services are rendered.

PAYMENTS

Patient portion is expected at the time services are rendered. This includes all deductibles, co-insurance, co-payments and any non-covered services such as cosmetic procedures. It should be noted that any procedure performed in the office, such as freezing a wart or performing a biopsy on a mole is considered “office surgery” by most major insurance carriers and may be subject to your deductible.

To simplify your experience when receiving care and to make the payment process transparent and convenient we use Health iPass check-in and patient payment system. All information is fully encrypted and protected. Once your insurance company processes your claim, you will receive an email notifying you of any remaining balance from today’s visit. We will automatically deduct that balance from the card you provided five business days after receiving the e-Statement.

PATHOLOGY

Pathology is ordered by our physicians to properly diagnose certain skin disorders. Charges for these services are billed to your insurance by the pathologist. Your skin sample may be sent to one of the following labs: Aurora Diagnostics: South Texas Dermatopathology, Quest Diagnostics or Pathology Reference Lab.

NO SHOW / LATE CANCELLATION

If you are unable to attend an appointment, please let us know as soon as possible so that we can assign your appointment time to another patient. We ask for at least 1 business day cancellation for all appointments. We reserve the right to charge the following “late cancellation fees” or “no show fees”: $35.00 for an office visit. As a courtesy, we make every effort to confirm appointments in advance; however, it remains YOUR responsibility to know and to keep your appointment. Emergencies will be considered on an individual basis.

LATE POLICY

If you are more than 15 minutes late to your scheduled appointment, we will make every effort to work you back into the providers’ schedule. However, we may have no choice but to reschedule your appointment.

REQUESTS FOR MEDICAL RECORDS and COMPLETION OF FORMS

There will be a charge of $25.00 per request. Upon receipt of payment, documentation will be returned or can be picked up within 5-7 business days, unless otherwise notified. You may access most medical records through your online patient portal at no cost to you by visiting https://txdermandlaser.ema.md/ema/PatientLogin.action

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Thank you for choosing Texas Dermatology for your healthcare needs. We are required by law to provide you with a copy of our Notice of Privacy Practices. To ensure that our records are accurate, please sign this form and return it to our receptionist to acknowledge that you have been provided with a copy of our Notice.

Medical History & Information



ROS

Past Medical History

Past Surgical History

Skin Disease History

Current Medications & Dosage

Social History

Family History

Allergy Wellness


Your signature will be required upon your next visit to our offices.

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