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4836 Van Nuys Blvd., Sherman Oaks, CA 91403
(818) 907-SKIN (7546)
dermatology
Cosmetic Surgery
Minimally-Intrusive Procedures
Aesthetic Services

Online Patient Registration

Registering on line at least 2 days prior to your visit will expedite your appointment  and permit us to verify your insurance  coverage and deductibles. If there is not ample time to confirm this information you will be responsible for the total cost of your initial visit at the time of service.
ABOVE PARAGRAPH

In most cases patient responsibility amounts are determined by your insurance carrier and benefits. Our office cannot guarantee that all services will be covered or that all services received are a benefit of your plan. Therefore, prior to your visit, we strongly recommend that you check with your insurance company regarding deductibles, co-payments and co-insurance amounts due.

In addition, please note our office is only contracted with PPO plans. We do not accept any HMO plans. If you are unsure of the type of plan you have please contact your insurance company directly.

New Patients: Please use this form to register with Mid Valley Dermatology after you have scheduled an appointment with us. Note that all of the patient information we collect is for use within our office only and is protected against unauthorized access. This form uses secure SSL encryption.

If you encounter any difficulty completely these forms on line, please call our office for assistance at (818) 907-7546.

Bold text shows required information. Text in green shows formatting examples or other special instructions.

This form uses SSL encryption.

Patient Information
Last Name  First Name
Middle initial Date of Birth [mm/dd/yyyy]
Address
Age
City Sex
State  ZIP Code 
Social Security Number [123-45-6789] Marital Status  
Driver's License #
Home Phone Mobile/Cell:
Email Address
Employer Work Phone
Occupation Spouses Name
Referred by (name) Referred by (address)
 
In Case of Emergency Contact:
 
Name Phone
Relationship to Patient Is the phone number above
Person Financially Responsible
COMPLETE ONLY IF DIFFERENT FROM PATIENT
Last Name First Name
Middle Initial Social Security Number
[123-45-6789]
Address
Date of Birth
[mm/dd/yyyy]
City Home Phone
Email Address
State Occupation
ZIP Code Employer
Drivers License Number Work Phone
Insurance Information
NOTE: These are REQUIRED FIELDS! Please enter "NA" if you are a cash patient or if the fields do not apply to you.
 
Primary Insurance Information Secondary/Supplemental
Insurance Information
  No
Yes
(If yes proceed to boxes below)		   No
Yes
(If yes proceed to boxes below)
ID# ID#
Group # Group #
Subscriber Name (if different from patient) Subscriber Name (if different from patient)
Subscriber Date of Birth
Subscriber Date of Birth
Insurance Name Insurance Name
Insurance Company Address Insurance Company Address
Insurance Co. Phone: Insurance Co. Phone:
(if phone number is not provided, we may not be able to verify your insurance benefit) (if phone number is not provided, we may not be able to verify your insurance benefit)
Relationship to Patient Relationship to Patient

Payment is expected at the time of service. For individuals with Medicare or PPO's with whom our office is contracted, please see below:

Assignment of Insurance Benefits
I understand that I am responsible for any deductible or co-payments at the time of my visit. I hereby authorize and request my insurance company to pay directly to the Doctor the remaining amount due on my claim for services rendered to me or my dependent. I am aware that my insurance company may determine that I am liable for additional fees; if that is the case, I will be responsible for payment of these fees. If my condition is found not to be a "covered" service or a cosmetic service, I am aware that I will be responsible for the entire fee. If it should be necessary to initiate legal proceedings to collect any unpaid amount, I will be responsible for all collection fees plus all interest charges.
I have read and acknowledged the above

WHEN YOU PRESS SUBMIT YOU WILL BE TAKEN TO A PAGE WITH A FEW MORE ITEMS TO FILL OUT: Part 2 COMPLAINT & HISTORY

PLEASE NOTE: Please wait for the next page to load. DO NOT CLICK SUBMIT MULTIPLE TIMES unless you are prompted to fill in a required field.


If you have any questions regarding this form or the questions, please call (818) 907-7546 and speak with one of our registration specialists. Our office is open Monday through Friday from 8:15 am to 5:30 pm.

This form uses SSL encryption.

 
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