Click on any of the links to view our patient forms. If you have a printer, you may optionally print the forms and fill them out at home prior to your appointment.

All forms require Adobe Acrobat - Get it Here!

New Patient Forms

  New patients can fill out their registration and medical history information and bring these
  forms in to speed up your initial appointment check-in process.

Bathing Procedures

Patient Treatment Care Instructions

Post Operative Mohs Surgery Care Instructions

 
 
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The fees that are charged in this office are comparable to those charged by other competent specialists in our fields. The following is a list of providers we are contracted with, however, contractual agreements are subject to change and we recommend that you contact your insurance carrier prior to your appointment to verify that your physician here is a contracted provider.

Aetna PPO
Aetna
- PPO
- POS Choice II
- Open Choice PPO
- Health fund PPO/POS
Assurant Health (Multi-Plan)
Az Foundation for Medical Care
Beech Street
Blue Cross Blue Shield
Cigna Medicare Replacement
Community Care Network of Az (CCN)
Cofinity
Coventry/First Health/Mail Handlers
Health Management Network
Humana Choice Care/ Humana Gold
- Excludes Humana Choice PPO (Medicare Advantage)
Integrated Health Plan
Medicare/ Medicare Railraod
Private Health Care Systems (PHCS)
RanAmn
Tricare for Life (Medicare Supplement)
United Health Care

We will bill any non-contract PPO insurance, however any difference between the amount paid by the carrier and the office charges are the patient’s responsibility. We do not accept any HMO’s.

Statements are generally sent 7 to 30 days after your visit depending on your insurance coverage. This varies significantly for certain types of accounts, so please do not be concerned if yours takes longer. Payment is required in full upon receipt of your statement.

Uninsured patients are required to pay at the time of service. If a procedure is done which requires a delay in full charges, partial payment is required.

Cosmetic Services - In this office some procedures are done which are classified as cosmetic corrections. Fees for this type of procedure are ordinarily paid for in advance.

 
 
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Notice of Privacy Practices:

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction:

At Allergy & Dermatology Specialists, Inc., we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your PHI. This Notice is effective April 16, 2003 and applies to all PHI as defined by federal regulations.

Understanding Your health Record/Information:

Each time you visit Allergy & Dermatology Specialists, Inc., a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment
Means of communication among the many health professionals who contribute to your care
Legal document describing the care you received
Means by which you or a third-party payer can verify that services billed were actually provided
A tool in educating health professionals
A source of data for medical research
A source of information for public health officials charged with improving the health of this state and the nation
A source of data for our planning and marketing
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to: ensure its' accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosures to others.

Your Health Information Rights

Although your health record is the physical property of Allergy & Dermatology Specialists, Inc., the information belongs to you. You have the right to:

Obtain a paper copy of this Notice of Information Practices upon request
Inspect and copy your health record as provided in 45 CFR 164.528
Obtain an accounting of the disclosures of your health information as provided in 45 CFR 164.528
Request communications of your health information by alternative means or at alternative locations
Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and
Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

Allergy & Dermatology Specialists, Inc., is required to:

Maintain the privacy of your health information
Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
Abide by the terms of this notice
Notify you if we are unable to agree to a requested restriction, and
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all PHI we maintain. Should our information practices change, we will mail a revised notice to the address you've supplied us, or if you agree, we will email the revised notice to you.
We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the practices' Privacy Officer at (623) 977-4218.

If you believe your privacy rights have been violated, you can file a complaint with the practices' Privacy Officer or with the Office for Civil Rights, (OCR), U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:

Office for Civil Rights U.S. Department of health and Human Services 200 Independence Avenue S.W. Room 509F, HHH Building Washington, D.C. 20201

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment.

For example:
Information obtained by a nurse, physician or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.
We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you're discharged from this hospital.

We will use your health information for payment.

For example:
A bill may be sent to you for a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

We will use your health information for regular health operations.

For example:
Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business associates

There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology department, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill you or your third-party payer for services rendered. To protect your health information however, we require the business associate to appropriately safeguard your information.

Directory

Unless you notify us that you object, we will use your name, location in the facility, general condition and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

Notification

We may use or disclose information to notify or assist in notifying a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

Research

We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Funeral directors

We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Organ procurement organizations

Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Marketing

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

Fund raising

We may contact you as part of a fund raising effort.

Food and Drug Administration (FDA)

We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.

Worker's Compensation

We may disclose health information to the extent, authorized by and necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Public health

As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Law enforcement

We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

 
 

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