Medical Visit forms

FORM & INFORMATION FOR YOUR MEDICAL VISIT

  1. New patients: Please print, fill out, and bring the New Patient Forms with you to your first visit to our office. Please download the forms below.
  2. If you are an existing patient, you may also use these forms to update your information.
  3. Please arrive 15 – 20 minutes early for your paperwork to be processed and to keep your appointment running on time.
  4. Please bring your Photo ID and Insurance Card.
  5. For a list of Insurances accepted, click here.

NEW PATIENT FORMS

Medical History

OPTIONAL FORMS

Registration
HIPAA / Advance Directive
Credit Card on File Agreement
Cosmetic Questionnaire

If the patient is under 18 years of age:
Please download and complete this form: Consent for Treatment of Minor


POLICIES

Understanding our commitment to you and your financial responsibility to us is an essential component to establishing and maintaining a strong patient/practice relationship. In order to achieve this, we offer the following information regarding our office policies click here.

PAYMENT

  • If you are a self-pay patient, your insurance company is not contracted with us, or you are receiving elective or cosmetic services, please be aware that payment is due at the time of service.
  • Some cosmetic services require prepayment (i.e. Botox treatments, dermal fillers, laser skin resurfacing, etc.).
  • As a courtesy to our patients, we file medical claims with most insurance companies. However, the involvement of the insurance companies makes the billing process extra complicated. If you have any questions regarding your billing statements, please let us know so that we can help you. Our business office can be reached at 520.396.1860.

FORMS OF PAYMENT ACCEPTED:

Cash
Personal Checks
Debit Cards (with a Visa logo)
Visa, Mastercard, American Express, & Discover
CareCredit – Pay Online Here

 

 

 

NO SHOW OR CANCELLATIONS:

  • As a courtesy, we will attempt to contact you prior to your visit via phone and/or email to confirm your appointment.
  • If you need to reschedule or cancel your appointment, please call our office at 520.795.7729 at least 48 hours in advance.
  • If you miss an appointment or cancel an appointment without a 48 hour notice, you may incur a charge of $40.00 or more, depending on the type of service scheduled. A scheduled Mohs surgery that is not cancelled 72 business hours prior will be subject to a $100.00 no-show fee. Cosmetic and Laser procedures require a minimum of a 48 hour notice to cancel or reschedule; failure to do so may result in the deposit being forfeited.


Section 1557 Nondiscrimination Statement

Pima Dermatology, PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Pima Dermatology, PC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. To learn more, please click here.

Patient Bill of Rights and Responsibilities

Patients have the right to considerate and respectful care. To read our Patient Bill of Rights and Responsibilities, please click here.

HIPAA Notice of Privacy Practices

This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. To read the Notice of Privacy Practices in full, please click here.

By Pima Dermatology | © 2018 All Rights Reserved. Design & Development by Goldman Marketing Group | Sitemap | The information available on this web site is provided for informational purposes only. This information is not intended to replace a medical consultation where a physician's judgment may advise you about specific disorders, conditions and or treatment options. We hope the information will be useful for you to become more educated about your health care decisions.