• Hours: Mon - Fri: 8:00am - 5:00pm
  • General Information

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  • Understanding & Agreement

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    I hereby authorize and assign my insurance benefits to be paid directly to Dermatology Health Specialists, P.C. I authorize release of information to facilitate treatment, payment or heath care operations. I give Dermatology Health Specialists, P.C. permission to treat me and take photographs. Co-payments and/or outstanding balances are due at the time of your appointment. I agree that I will be financially responsible for any treatment I receive, in the event that my insurance company denies payment. I will be responsible for a $50 fee in the event that: (1) my check is returned for insufficient funds, or: (2) my account is turned over to a collection agency, or; (3) I fail to show up for my appointment and have not notified your office at least two business days in advance of the appointment. I understand that any illicit, sexually suggestive or otherwise inappropriate behavior by me may result in immediate termination of service and dismissal. By typing my name below signifies my understanding and agreement to comply with these policies.

    I have read and understand the Notice of Privacy Rights and Practices and Dermatology Health Specialists Policies.

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