PLEASE INITIAL EACH SECTION BELOW TO INDICATE YOU HAVE READ AND UNDERSTAND THE INFORMATION:
I, by my signature below, as the patient OR his/her representative, do hereby authorize Coastal Skin Surgery and Dermatology, to release to my insurance company(s) or other appropriate agency(s) that information which is necessary to validate this claim. Coastal Skin Surgery and Dermatology, is also hereby authorized to release to my physician(s), whether as an individual(s) or as a professional association, who perform services for me, the patient, on a fee for service basis such information as is necessary for billing purposes. I hereby authorize Coastal Skin Surgery and Dermatology, to release any medical information to physicians other than original referring providers, who may be involved in my or my dependent’s health care treatment, when requested by these physicians. By signing this consent, information will be given to requesting providers without further signed authorization. I hereby give permission to disclose, discuss and speak to listed individual(s) concerning my medical or financial information including, appointments, test results, prescriptions, school or work excuses, etc. (We must have each individual listed by name. This includes your spouse, children, parents, etc.)
May we leave personal information on the following? (Select all that apply)
Coastal Skin Surgery and Dermatology encourages patient involvement in their health care. Online access to health information allows patients to make informed decisions about their care and share their most recent clinical information with other health care providers and personal caregivers. You will receive an email from us following your visit today that will invite you to access our patient portal. You will be sent the link and information to go to and verify your identity. Once verified, you will be asked to set a password. You can then sign on to access your contact information, insurance and pharmacy information, skin disease history, social & family history and your problem list. Your visit notes, educational handouts and any test results related to a specific visit can be viewed also by selecting the date of your appointment. You are able to also send messages to your provider and your provider can message you in return. We are happy to answer your questions regarding access and use of your patient portal. You may choose to "opt out" or not access your information by not responding to our patient portal email and verifying your information. The link will expire 72 hours from the time it is sent to you, but you can still access the portal by your user name (your email address) and choosing "forgot password". You may also request at any time to have your invitation resent for activation of your patient portal.
The URL to access the patient portal is: Coastalskinsurgery.ema.md Choose: "Patient Login"
(type only the URL information-no https or www.-above and you must use either Mozilla Firefox or Google Chrome web browser