Welcome to Lincoln Road Dermatology

Welcome to Lincoln Road Dermatology! Thank you for choosing us for your skincare needs. We are delighted to welcome new and returning patients and are committed to providing high-quality care. Our office is conveniently located at 1680 Michigan Ave, Suite 1016, Miami Beach, FL 33139.

Important Information About Your Visit:
1. Timeliness & Scheduling
We value your time and strive to maintain punctuality. Please plan to arrive 10–15 minutes early to allow time for registration, including updating information on our iPad system. Arriving more than 15–20 minutes late may result in a missed appointment, requiring rescheduling. We prioritize quality over quantity so we avoid overbooking. There is no guarantee that we will be able to fit you into the schedule, but we often try our best.

2. Credit Card on File (CCOF)
All patients are required to keep a credit card on file. Upon arrival, you will be prompted to input your credit card information into our system securely. Payments, including copays, co-insurance, and deductibles, are due at the time of service. If insurance denies or does not cover services, any outstanding balances will be charged to your card. Balances over $10 will be notified via text, and refunds will be processed back to the original card.

Our billing team charges your credit card on file for balances owed for past services and missed appointment fees shortly after missed appointment. For account balances owed from insurance-based services, you will receive notification of your financial responsibility via your insurance company, and invoices will be texted to you from our billing system. After two (2) unanswered text reminders, we process any remaining balances to your credit card on file.

All other charges are due at the time of service.

3. Payment Responsibility

Self-pay or noninsurance-based patients will be offered a $200 discounted self-pay rate for medical consultations, which are due at the time of service. Cosmetic consultations are additional.

--Additional charges to your consultation include: (1) Any procedures or lab work (cultures or lab processing of skin samples) performed during your visit will incur additional charges. (2) Any procedures such as injections, biopsies, or procedures (3) extensive paperwork or prior authorization on your behalf beyond the date of your office visit.

Commercial or Federal Insurance-based patients: Our website has a list of insurances we accept. If we are not in-network with your insurance or if benefits cannot be verified, payment in full is required at the time of service. Our system can provide estimated costs that are due at the time of service and typically include Copay, co-insurance, and deductible amounts owed.

Insurance company denials: After billing your insurance, you may receive a higher-than-normal bill if your claim is denied. Please get in touch with our billing department immediately to discuss payment options, as you will be left with a balance. The consultation fee may only be reduced to a discounted rate of $225 and will be your responsibility; any procedures or lab fees will be additional. (Please note: if your insurance covers your claim according to your policy, per contract, the amount owed is your responsibility and cannot be discounted under any circumstance.

Procedure costs will be discussed beforehand.

Refunds. Refunds can be promptly issued to your credit card on file for any over payments.

Note: We do not accept Medicaid, including self-pay Medicaid patients. Please consult your insurance directory for options.

Additional charges to your consultation include: (1) Any procedures or lab work (cultures or lab processing of skin samples) performed during your visit will incur additional charges. (2) Any procedures such as injections, biopsies, or procedures (3) extensive paperwork or prior authorization on your behalf beyond the date of your office visit.

4. Laboratory Fees
Skin swabs or biopsies are sent to external labs (Quest, Ameripath, Pathology Watch, Bayshore Pathology). Your insurance determines lab fees and are your responsibility. Self-pay patients will have these fees included in their procedure costs.

5. What to Bring
Always bring the following to your appointment:

A valid photo ID (e.g., driver’s license).
A form of payment.
Your insurance card.
If your insurance or payment information has changed, notify us before your appointment.

6. Missed Appointment & Cancellation Policy
Cancellations or rescheduling require at least 24 hours’ notice.
Missed appointment fees are as follows: $50 for medical visits.
$75 for aesthetic, laser, cosmetic, or surgical visits.
These fees are not covered by insurance and must be paid before rebooking. Future appointments will also require a deposit for repeat missed appointments. We apply this policy broadly and without prejudice to compensate for the time reserved.

7. Safe & Respectful Environment
We maintain a zero-tolerance policy for incivility to ensure a respectful environment for all. While we are happy to help clarify insurance details, your responsibility is to understand your policy, including exclusions and lab costs, before your visit.

After submitting this form, our office will confirm or reach out to schedule your appointment within 24–48 hours.

Additional Information
Please review our HIPAA, financial, and patient policies on our website:
www.lincolnderm.com/officeinfo.

Scheduling appointment*

I already requested a specific time and date through the website schedulerI need to be contacted by the office to schedule an appointment

Form type*

Last Name*

First Name*

Date of birth*

Phone*

Cellular phone

Is this phone number capable of receiving text messages about appointments, biopsy callbacks, billing, or other important information?*

yesno

E-mail*

Correspondence regarding your care will go here so please use private email.

Address*

Street Address

Include apartment

CityState / Province

Postal / Zip Code

Gender*

FemaleMaleOther

Do you have health insurance*

Yes, I will upload a copy of my current/active insuranceNo, I will be self payYes but your office does not participate and I will be self pay

Please upload a copy of your insurance card(s) both front and back. Please indicate below which is your primary card.*

Browse Files

You can take or upload photo from your phone

If you have 2 health insurance cards, please indicate below which insurance card is primary vs secondary.

Upload photo of front of driver's license or ID*

Browse Files

Required. You can take or upload photo from your phone.

Please state the nature of your intended visit:*

To ensure proper scheduling, your visit will only address your above concerns. Note cosmetic concerns or consultations are not part of an insurance base visit. Please book a cosmetic visit to address any cosmetic issues. a separate appointment from medical appointments.

Who is your primary care doctor?

Please remark if doctor is not local

How did you hear about us?

Please note: All information in this form is for administrative input in anticipation of scheduling a medical visit or telemedicine visit. Any correspondence does not create a doctor patient relationship or initiate care of medical condition. Any communication via our website and/or email cannot replace the relationship you have with a physician. If you feel your situation is an emergency, please call 911 or go to the nearest emergency room.

Date*

Date

By signing below, I acknowledge that I have read and had time to review the policies of the office as it pertains to: missed appointments, consent to received information via voicemail, text, email messaging. I have been given the opportunity to review the policies on the website with regards to patient privacy, HIPAA, financial and insurance policies and acknowledge that LRD is out of network with Medicaid and that I do not have a Medicaid based plan. Signature*

PATIENT FORMS v2025