Forms

Forms

Patient Forms & Info

1. New Patient Registration Forms | Fill Out Online

2. New Spa Client FormĀ | Fill Out Online

3. COVID-19 Liability Release Waiver | 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. Photo Consent Form for Release of Clinical Photos | Fill Out Online

8. Latisse Consent Form | Fill Out Online


Insurances & Billing

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

  • United Healthcare
  • Medicare
  • Cigna
  • Carefirst Blue Cross Blue Shield
  • Anthem Blue Cross Blue Shield (PPO plans only)

We are out-of-network providers for all other health insurance plans and do not accept them. We do not submit claims for insurances that we do not accept (out-of-network insurances). Payment for all visits which are not submitted to insurance is due in full at the time of service. All sales are final. We accept Visa, MasterCard, Discover, and American Express credit cards. We do not accept checks.

If your insurance requires referrals or pre-authorizations in order for your services to be covered, you must obtain these prior to your visit. 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 billing department at 1-800-300-7819.


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