Forms

Forms

Patient Forms & Info

1. New Patient Registration Form – ADULTS (AGE 18 AND OVER) | Fill Out Online

2. New Patient Registration Form – MINORS (UNDER AGE 18) | Fill Out Online

3. New Spa Client Form | Fill Out Online

4. HIPAA Authorization for McLean Derm to Release Health Information | Fill Out Online

5. HIPAA Authorization for McLean Derm to Obtain Health Information from another Facility | Fill Out Online

6. Permission for a Minor to be Seen Without a Parent/Legal Guardian | Fill Out Online

7. Financial Agreement & Acknowledgement of Privacy Practices 2023 | Fill Out Online

8. Photo Consent Form for Release of Clinical Photos | Fill Out Online

9. Latisse Consent Form | Fill Out Online

10. Upneeq Consent Form | Fill Out Online

11. Request For Meeting With Providers | Fill Out Online


Insurances & Billing

We are in-network providers for the following insurance plans:

  • Aetna
  • Anthem BCBS
  • Federal BCBS
  • Carefirst Blue Choice
  • Cigna
  • United Healthcare
  • GEHA
  • UMR
  • Medicare

Insurances REQUIRED to have an insurance referral:

  • Cigna HMO
  • United Healthcare Optimum Choice Plan
  • United Healthcare MDIPA
  • All HMO Plans

We cannot guarantee that we accept your specific plan as an In-Network provider; it is your responsibility to verify your insurance benefits and coverage prior to your visits. We are out-of-network for all other health insurance plans and do not submit claims for out-of-network insurances. Payment for all visits which are not submitted to insurance is due in full at the time of service. We accept Visa, MasterCard, Discover, and American Express credit cards. We do not accept checks.

If your insurance requires a referral in order for your services to be covered, you must obtain these prior to scheduling. If your insurance requires a referral for your visit and it is not processed and received by our office prior to your visit, you will likely need to reschedule your appointment.

We use third-party labs for biopsies, blood work, and cultures. If your insurance requires use of a specific lab in order for laboratory fees to be covered, you must notify us about this prior to your visit.

If you have questions about your bill, please contact our office at 1-703-356-5111 and ask for the billing manager.

 

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Schedule an Appointment

To schedule an appointment, call (703) 356-5111.


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