Patient Forms

To expedite your check in process, please fill out, print the documents below, and bring them with you when you come to our office for your visit. (*Data typed in this form cannot be saved*)

If you would like to email your completed registration forms, you can send it to AD.Questions@arlingtondermatology.net

If interested in learning more about skincare and other skin procedures we offer, please feel free to fill out this cosmetic questionnaire and bring it to your next scheduled appointment for a skin consultation.

Insurance Information

HMO

Health Maintenance Organization. A form of health insurance combining a range of coverages in a group basis. A group of doctors and other medical professionals offer care through the HMO for a flat monthly rate with no deductibles. However, only visits to professionals within the HMO network are covered by the policy. All visits, prescriptions and other care must be cleared by the HMO in order to be covered. A primary physician within the HMO handles referrals.
Accepted HMO’s:

  • Blue Cross Blue Shield IPA-site 197
  • Blue Cross Blue Shield Blue Choice
  • United healthcare POS. EPO (No referral necessary)

PPO

Preferred Provider Organization. A health care organization composed of physicians, hospitals, or other providers which provides health care services at a reduced fee. PPOs may also offer more flexibility by allowing for visits to out-of-network professionals at a greater expense to the policy holder. Visits within the network require only the payment of a small fee. There is often a deductible for out-of-network expenses and a higher co-payment. A policy holder will have a primary physician within the network who will handle referrals to specialists that will be covered by the PPO. After any visit, the policy holder must submit a claim, and will be reimbursed for the visit minus his/her co-payment.

  • Most PPO networks are accepted. To verify please contact the office.

Medicare Assignment

A federal program that pays for certain health care expenses for people aged 65 or older. Enrolled individuals must pay deductibles and co-payments, but much of their medical costs are covered by the program. Medicare is less comprehensive than some other health care programs, but it is an important source of post-retirement health care. Medicare is divided into three parts. Part A covers hospital bills, Part B covers doctor bills, and Part C provides the option to choose from a package of health care plans.

  • Secondary plans under Medicare are accepted.

Medicare Replacement plans

*Notice to patients

Patients with Medicare Replacement plans must contact our office to verify eligibilty of their insurance plans. Coverage under these plans may be limited. To ensure patient visits are covered, please provide your full insurance information when scheduling an appointment.

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