New Patient Information

Balcones Dermatology & Aesthetics Contents Patient Resources New Patient Information

 

Linked below are new patient forms needed for your upcoming appointment.

Please follow the steps below to complete your new patient information. Then print and complete the following two forms (the Acknowledgment of Receipt of Notice of Privacy Practices and the HIPPA Notice of Privacy Practices) and return them by mail or fax, as soon as possible, along with a copy of your insurance card (front and back). If your insurance requires a referral and you have received it, please enclose a copy of the referral. We must have a copy of your insurance card (front and back) in order to verify benefits and be prepared for your visit. The “Notice of Privacy Practices” is for your records and we do not need it returned.

Please note that patients who do not cancel their appointment 24 hours before and/or miss their appointment will be charged $35.00 for a missed routine visit and $100.00 for a missed surgical procedure.

Thank you, in advance, for your cooperation in assisting us with being prepared for your appointment. We hope your visit is a pleasant one.

Step 1: Download and read the instructions for new patient demographics.

Instructions For Patient Demographics

Step 2: Click on Patient Login to complete the registration process.

Step 3: Download, print and complete the following privacy notices. Please bring these documents to your appointment.

Acknowledgment Of Review Of Privacy Practices

HIPAA Notice Of Privacy Practices

Here’s a list of other forms and resources on our site:

If you have any questions about our forms or need help filling them out, please contact us.