PATIENT RESOURCES

(There will be two additional forms when you arrive for your appointment.)

Patient Demographic Information Form
Medical History Form

This form is needed to release medical records. New patients do not need to fill this out unless you want your records to be sent to another physician.

Medical Records Release Form

• www.dermnetnz.org
• www.aad.org/public/diseases

Please note, there is a $35 no show and cancellation fee if your appointment is not cancelled within 24 hours of your appointment.

For billing questions, please contact our contracted billing company MEDCOMM at 1-614-553-0997. Please have your patient account number handy or include it in your email so we can assist you better.

Co-payments and deductibles are due at the time of your visit. Per federal law, you must have your insurance card and photo ID at each visit. If you have questions, please call (614) 898-7546 to speak with a billing associate or manager prior to your appointment.

You are responsible for all costs not covered by insurance. For out-of-pocket expenses, including deductibles, co-insurance and co-payments, we accept Visa, MasterCard and Discover credit cards, as well as personal checks and cash.

AARP MEDICARE COMPLETE

AETNA/AETNA MEDICARE

AETNA TRINITY HEALTH

ALLSAVERS

AMERIBEN

ANTHEM/ANTHEM MEDICARE

ASSURANT HEALTH

BEECH STREET

BLUE CROSS BLUE SHIELD

BUSINESS ADMIN CONSULTANTS

CIGNA/GREAT WEST CIGNA

FIRST HEALTH

GEHA

GOLDEN RULE

HUMANA/HUMANA MEDICARE

KLAIS & CO

MAILHANDLERS

MEDBEN

MEDICAL MUTUAL

MEDICAL MUTUAL HMO

MEDICARE/RAILROAD MEDICARE

MEDIGOLD PPO & HMO

MERITAIN HEALTH

MUTUAL OF OMAHA

NATIONWIDE

NGS/CORESOURCE

OPTIMA HEALTH/OHIO HEALTHY

OSCAR

PHCS

PRINCIPAL MUTUAL LIFE

PRUDENTIAL

TRICARE/TRICARE FOR LIFE

TRUSTMARK

UMR

UNITED HEALTHCARE

UHC NAVIGATE

UHC MEDICARE COMPLETE

UHC MEDICARE COMPLETE HMO
UHC NAVIGATE

We are not providers for any Medicaid or Dual Advantage plans.
If your plan requires a referral to see a specialist, please ensure one is in place prior to your scheduled appointment; otherwise, we may need to reschedule.
If you do not see your insurance listed here, please contact our office and/or your insurance company to find out if we are in-network for your plan