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.
