Welcome to Lincoln Road Dermatology

Thank you for choosing Lincoln Road Dermatology for your skin care needs. We are currently accepting new patients and look forward to providing the best possible, individualized care. We are at our new location on 1680 Michigan Ave, Suite 1016, Miami Beach, FL 33139.

Things to know about our office:

1. We strive to run on time and know your time is valuable. To this aim, plan to arrive 10-15 minutes prior to your scheduled appointment time for registration and ipad update required at each and every visit. We prefer to schedule lightly and avoid a mill like atmosphere. Arriving 15-20 past your scheduled time may result in a missed appointment and you will ask to be rescheduled.

2. We require credit card on file (CCOF) for all patients. You will be prompted on arrival to input your credit card into our system. Payment is due at the time of service and any estimated costs will be collected (copayment, co-insurance and deductible). Having insurance does not guarantee payment for services rendered. If services are denied or not covered by your insurance for whatever reason, it will leave a balance on your account to be settled via CCOF. You will be notified via text message for all balances over $5. Any refunds owed will be placed back to the original paying card.

3. Please be aware of your unique insurance policy. It is your responsibility to know your insurance benefits and if a referral is needed. If you need any clarification of services covered, please call your insurance company. Self pay rates for consultation are $175 and will be your responsibility if your insurance does not cover your visit.

4. Kindly bring 3 items to every visit: 1) a valid ID (driver's license), 2) form of payment and 3) your insurance card. If your insurance or credit card information has changed, please let us know prior to your appointment.

5. We charge for missed appointments/no shows. A $50 nonrefundable deposit is needed to secure your first appointment. This deposit will be applied upon arrival to your 1st scheduled visit unless you do not show or last minute cancel. We require >24 hours notice from your appointment time to cancel or reschedule or missed appointment charges will go on your account. Fees for missed appointments: $50 for medical, $75 for esthetic, laser, cosmetic, surgical appointments. These fees are not covered by your insurance and must be settled prior to rebooking.

A list of insurances our office is contracted with can be found on our website. If we are not directly contracted with your insurance or we cannot verify your insurance benefits, you will be asked to pay in full at the time of visit. Appropriate refunds can be easily issued if your insurance later covers your services.

NOTE: we do not participate with Medicaid and cannot see any Medicaid patients as self pay. Please consult your insurance’s directory.

After receipt of this form, our office will confirm or reach out to you to schedule your appointment or approve your requeted appointment within the next 24-48 hours.

Kindly review our our HIPAA, financial and patient practice policies on our website at www.lincolnderm.com/officeinfo.

Have you been to Lincoln Road Dermatology before?*

Yes, I am an existing patient with no changes of my demographicsYes, I am an existing patient and need to update my demographicsNo, I am a new patient

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

Full name*

First NameLast Name

Date of birth*

Phone*

Cellular phone

Is this phone number able to receive text message correspondence regarding appointment times, requests for call back for biopsies, billing or other pertinent 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

You can take or upload photo from your phone

Please state the nature of your intended visit:*

Please be specific in order for our staff to ensure proper scheduling. Note cosmetic consultation is 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*

Clear

PATIENT FORMS v2023.2