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.

HIPAA CONSENT

I hereby permit Texas Dermatology and Laser Specialists to use my health information, and/or to disclose my health information to any third-party payor (health insurance company), or to any party involved in my health care. I understand that there is a Notice of Privacy Practices in the practice reception area available for me to read. This consent shall be in force and effect as long as I am a patient at this practice. I understand that I have the right to revoke this consent, in writing, at any time by sending such written notification to my physician(s) at this practice. I understand the information used or disclosed pursuant to this consent may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I also understand that I have the right to: Inspect or copy the protected health information to be used or disclosed as permitted under federal law; refuse to sign this consent form.

EMAIL CONSENT

I understand that by providing my email address on my patient data sheet, I am subject to receiving email communication from Texas Dermatology and Laser Specialists but am able to request to be removed from the mailing list at any time.

PAYMENTS

Patient responsibility is expected at the time services are rendered. This includes all deductibles, co-insurance, copayments, 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 require patients to authorize the card on file via the pocket patient app, the patient portal during pre-visit checkin, or via the patient kiosk at time of in-office check-in. All information is fully encrypted and protected and will not be charged without your consent. 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 via text or email. If you do not wish to leave your card on file, you may pay for services in full at time of visit and request a copy of your claim form to submit to your insurance carrier for reimbursement. We do not accept cash or check payments.

NO SHOW/ LATE POLICY

If you are unable to attend an appointment, please let us know as soon as possible. We ask for at least 48 hours for the cancellation of all appointments. We reserve the right to charge the following “late cancellation fees” or “no show fees” of $50.00 for office visits, and 50% of quoted fees for procedures or surgeries. As a courtesy, we make every effort to confirm appointments in advance; however, it remains patient responsibility to know and to keep appointments. Emergencies will be considered on an individual basis. 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.

CLAIM DENIALS

Texas Dermatology will bill patient insurance plans as a courtesy to our patients. It is patient responsibility to ensure information provided is true and accurate. You must confirm with your insurance company that our group is in-network with your policy prior to your scheduled appointment. To avoid claim denials, please submit all primary, secondary, and tertiary insurance information to us. If your claim is denied for any reason, you will be billed for services rendered based on a self-pay fee schedule.

PATHOLOGY/LABWORK

Pathology readings and blood testing is ordered by our physicians to properly diagnose and treat certain skin disorders. Charges for these services are billed to your insurance by the pathologist or processing lab. Your skin sample or bloodwork may be sent to one of the following labs: Pathology Watch, Aurora Diagnostics: (South Texas Dermatopathology), Quest Diagnostics, Pathology Reference Lab, Sagis, or LabCorp. Our providers make every effort to send lab work to the corresponding lab authorized by your insurance company, however, if you have a specific lab you wish to use, please inform your provider in the exam room at time of testing.

REQUESTS FOR MEDICAL RECORDS and COMPLETION OF FORMS

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 There will be a charge of $35.00 per paper request. Upon receipt of payment, documentation will be returned or can be picked up within 5-7 business days.

COSMETIC APPOINTMENTS

Cosmetic consultation appointments do not include time for treatment. Your provider will assess your skin and recommend a treatment plan based on your skincare goals during your consultation. Some patients are recommended to start a dermatologic treatment plan before beginning cosmetic treatments, so that the underlying skin condition can be treated first. There is no additional fee for the dermatologic treatment plan recommended by a dermatologist or physician assistant. A late cancellation fee equal to 50% of cosmetic service(s) will be charged if an appointment is cancelled within 48 hours of the reserved appointment time. Late arrivals past 15 minutes are subject to be rescheduled or worked in same day if possible. Any missed appointments will be charged in full.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We are required by law to provide you with a copy of our Notice of Privacy Practices. If you would like a copy of this policy, please ask the front desk receptionist. 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.