INTAKE FORM Lincoln Road Dermatology

WELCOME TO LINCOLN ROAD DERMATOLOGY!
Thank you for trusting us with your dermatologic care. To ensure a seamless and positive experience, please review this summary of our key policies. You will be required to sign the full financial and office consent form during your visit. For complete details, visit our website at lincolnderm.com/patient-resources.

CREDIT CARD ON FILE REQUIREMENT
Our office requires a valid credit card on file (CCOF) for all patients as a first step to being seen. This ensures timely payment for balances, including copays, deductibles, coinsurance, cosmetic or elective services, and any denied insurance claims. Adding a CCOF cannot be bypassed and is part of the check-in process.

CHECK-IN REQUIREMENTS
Please arrive 10 minutes prior to your appointment to update or input your medical information in our iPad system. Bringing your insurance card, ID, and a valid form of payment will help streamline the process. Kindly note that we do not accept checks.

INSURANCE RESPONSIBILITY
It is your responsibility to understand your insurance plan and verify if we are in-network. Our office relies on an insurance verification system to confirm coverage to the best of its ability; however, this system is not infallible, and we cannot guarantee its accuracy. Any costs not covered by insurance remain your responsibility. If your insurance denies coverage or delays payment, up to $225 may be collected from your CCOF for the consultative portion of the visit.

PAYMENT POLICIES
Payment is required at the time of service for all anticipated copays, deductibles, coinsurance, cosmetic or elective services, self-pay services, and in-office purchases. Cosmetic consultations are separate from medical visits and incur a fee, as they are not covered by insurance.

LAB FEES AND PROCEDURES
Most lab services, such as pathology, are performed by independent labs and billed directly to you. For self-pay patients, we provide upfront pricing and process payment on your behalf. In-office procedures, such as biopsies or cryotherapy, are billed separately from consultation fees.

MISSED APPOINTMENTS
Missed appointments or late cancellations (less than 24 hours’ notice) will incur a $50 fee for medical visits and a $75 fee for surgical, cosmetic, or aesthetic visits. First-time no-shows require an additional $50 deposit to reschedule.

MEDICAL PHOTOGRAPHY AND TELEMEDICINE
I consent to medical photography for records and telemedicine services if agreed upon. If telemedicine coverage is denied, I understand I am responsible for a $225 fee.

HIPAA COMPLIANCE AND COMMUNICATION
I acknowledge that Lincoln Road Dermatology’s Notice of Privacy Practices and Florida Patient Bill of Rights are available online. I consent to receive communications via phone, text, or email regarding appointments, billing, and medical results.

SMALL LOBBY NOTICE
Our lobby space is limited, so we kindly ask that you avoid bringing large items such as skateboards, bikes, or scooters into the office. This helps us maintain a safe and welcoming environment for all patients.

ACKNOWLEDGMENT
By signing below, I confirm that I have reviewed and understood this summary of policies. I agree to the terms outlined and acknowledge I will sign the full consent form during my visit.

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*

MonthDayYear

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.*

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*

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*

MonthDayYear

By signing below, I acknowledge that I have read and had the opportunity to review the office policies regarding missed appointments, consent to receive communication via voicemail, text, and email, as well as other relevant procedures. I confirm that I have been given the chance to review the office’s policies on the website, including those pertaining to patient privacy, HIPAA compliance, and financial and insurance policies. I understand that Lincoln Road Dermatology is out of network with Medicaid, and I do not have a Medicaid-based plan. Furthermore, I acknowledge that if I present as an insured patient, and my insurance does not cover my visit for any reason, I agree to pay the self-pay rate of up to $225 for the consultative portion of my visit and authorize the charge to my credit card on file (CCOF) accordingly. Signature*

PATIENT INTAKE FORM 2025