New Patient Forms
Note: Please Print Each Page Individually--Do Not Print On Front And Back Of One Page.
We currently accept most major health insurance plans. Please check with our staff when making an appointment. If you have questions about insurance participation, contact your insurance company at the phone number listed on the back of your card. Cash, checks, Visa & Mastercard also accepted.
~~~~We MUST have a current copy of your insurance card at each visit.~~~
Sorry, but we DO NOT accept emailed insurance cards or pictures on cell phones. Please print your card out and bring it with you to your appointment!!
There are MANY different insurance plans, therefore if you are unsure whether or not we are your plan participant, please contact your insurance company directly prior to your appointment.
Established Patients: Should your current demographic and medical history forms be filled out before 2017, you will need to complete new forms prior to being seen.
APPOINTMENTS ONLY---NO WALK INS PLEASE!!!
Closed every day for lunch from 12:00-1:00
Tricare and Medicare Patients
Your insurance still requires us to obtain your Social Security Number in order to verify eligibility, referrals, authorizations and to file claims on your behalf. Please provide this number when filling out your paperwork. If you do not provide this number, we will be unable to file your claims and therefore, you will be entered as a self-pay patient.
Our staff needs to verify your insurance and demographic information at each visit. This may take a few minutes, but it is essential that we have the correct information to serve you best.
Complimentary consultations are available at MedSpa 360 only.
All cosmetic products and procedures can be discussed free of charge with our esthetician.
Should you need a refill on your medication, please request one from your pharmacy. Most prescriptions written by our office have refills. Your pharmacy will be able to let you know if you have any refills left on your prescription. They will usually contact us via fax seeking authorization if necessary. Refill requests are usually handled within a 48 hour time period. Please do not wait until the last minute to request a refill. If you are overdue for a follow-up, you may be asked to schedule an appointment to make adjustments to your medications or to try something new before refill requests are approved.
We appreciate a 24 hour notice when an appointment must be cancelled or rescheduled. We have an answering service that you may leave a message on. Missed appointments are assessed a $50.00 No Show fee. If you are more than 15 minutes late for your scheduled appointment, you may be required to reschedule your visit.
Under Aged Patients
No child under the age of 18 will be seen without the presence of a parent or guardian (with legal documentation). After the initial visit and upon the parent's written authorization, a child of driving age may be seen without a parent provided they are able to furnish current insurance cards, referrals and all necessary documents needed at the time of their visit. Please remember that if anyone other than the parent or legal guardian (with documentation) brings a child under the age of 18 to their appointment, a written, signed note stating the name of the person(s) bringing the child MUST be provided. Otherwise, we will be unable to see that patient.
It is your responsiblity to provide this office with updated insurance information at every appointment. If you do not provide us with a current/active insurance card and would still like to be seen by the physician, payment will be due in full at the time services are rendered. Otherwise, you will be asked to reschedule your appointment. Charges may include, but are not limited to, office visit, procedures, labs and pathology.
It is also your responsibility to request a referral from your primary care doctor if your insurance requires it for you to see a specialist and to bring it with you or have it faxed over to our office prior to your appointment. Should you not know if you need a referral to see us, please call your insurance company. If we do not have the necessary referral when you come in, you will need to reschedule your appointment.
Medical Record Retention Policy
We are happy to maintain your records while you are an active patient or to transfer your records to another practitioner or health care provider should you wish to seek care elsewhere. We consider patients inactive if they either ask to have their records transferred or they have not been seen in our office for six (6) years. Our policy is to destroy inactive medical records in accordance with the Department of Health Professions regulations that protects patient confidentiality, such as incineration or shredding.
There will be a $100.00 no show fee for cosmetic procedures (Botox, Fillers and Laser) . We would like a 48 hour notice should you need to cancel. This allows us to provide time for another patient. Should you be seen for medical advice in addition to the cosmetic procedure on the same day, please be aware that we will collect a copay/co-insurance and bill to your insurance company. Methods of payments for cosmetic procedures are cash and credit card only.
Our office participates with the following plans:
Aetna (Call your insurance company to see if we are a preferred provider with your specific plan.)
Anthem (PPO, HMO)
Anthem Healthkeepers Plus
CareFirst (PPO, HMO)
Cigna (PPO, HMO)
Mail Handlers Benefit Plan
MAMSI Life and Health
Medicaid (Check with your particular plan to see if we participate before your appointment)
Medicare (In 2021, there are many different Medicare plans. Please contact them prior to calling our office to see if we are a participating provider with your particular plan.)
Tricare Standard and Prime
United Healthcare (Call your insurance company to see if we are a preferred provider with your specific plan.)
This list is subject to change and is not a guarantee of participation or payment. The final determination is made by your insurance company. Please contact them for verification.
Payments for copays and coinsurances can be made by cash, check, Visa and Mastercard only. Returned checks are subject to a $50.00 fee.