New Patients/Forms
Registration
At least 3 days before your first appointment with us, you will need to Pre-Register. This will allow us to serve you in a more efficient and timely manner when you arrive in the office. Please DO NOT fill these forms out if you do not have an appointment scheduled with us yet.
There are two options available:
Online: Below you will find links to the forms necessary to register for your appointment. Please fill out all of the forms listed under the heading that applies best to your situation. Each form has a submit button you must press to have your information transferred directly to our secure server.
Phone: If you are unable to access the forms, one of our staff members will contact you 3-7 days before your appointment to request the necessary information.
HIPPA Compliant Online Forms: The following PDF forms are downloaded to your computer where you will complete them offline. When the Submit button at the bottom of the form is selected, the form is transmitted via the LuxSci secure server. For more information, please visit the LuxSci HIPPA link below.
Secure Internet Services
IMPORTANT - PLEASE READ BEFORE USING FORMS: To effectively submit these forms, you need to use Adobe Reader. Some computers default to a different PDF reader, so please confirm Adobe Reader is launched before completing forms (please see FORM TIPS at right to streamline process). This free program may be downloaded by clicking the link at the bottom of this page.
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Forms for Patients under 18
(see above important note)
- > Minor Patient Registration
- > Medical History
- > Minor Treatment & Credit Card Permission
- > Financial Policy
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Forms for Patients with Medicare
(see above important note)
- > Medicare Registration
- > Medical History
- > Financial Policy
- > Credit Card Authorization
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Forms for All other patients
(see above important note)
- > Patient Registration
- > Medical History
- > Financial Policy
- > Credit Card Authorization
Privacy Notice PDF (see above note)
Welcome to Dermatology Associates of West Michigan
Thank you for choosing one of our providers for your dermatological needs. It is our goal to provide you with the highest quality medical care available.
Please be aware that any patient under the age of 18 must be accompanied by a parent or legal guardian at their first appointment to receive treatment.
Please complete the appropriate forms on the left at least 3 days before your appointment. Below are items you will need to bring to your appointment in order for us to serve you effectively:
- > Current insurance cards
- > Drivers License or State ID
- > Co-Pay (the specialist co-pay amount per your insurance contract, if applicable)
No-Show/Cancellation Policy:
We require 24 hours notice of any change or cancellation of appointments. This gives us the opportunity to use the time to care for other patients. Please be reminded that it is very important that you keep your appointment as scheduled. If appointments are missed or cancelled, you may be charged a $25 fee.
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Insurance
- Aetna
- Blue Cross Blue Shield Plans
- Blue Care Network
- PhysiciansCare Health Plans
- Priority Health (HMO/PPO/ASP/POS)
- Cofinity (formerly PPOM)
- Tricare/CHAMPVA
- Medicare
- Aetna Medicare
- BCN Advantage
- Medicare Plus Blue PPO
- Humana Medicare
- PriorityMedicare
- We do not accept any form of Medicaid.
We are contracted with the following insurance carriers:
Payment
If we are not contracted with your insurance plan, payment is expected in full at the time of service. We accept cash, check, MasterCard, Visa, Discover, and American Express.
Map
Please click here for a map and additional contact information. Please feel free to call our office at (616) 949-5600 if you have any questions.
FORM TIPS: Please follow these tips for accurate delivery of forms
IMPORTANT - ALL USERS: FORMS ARE NOT COMPATIBLE WITH GOOGLE CHROME
PC Users
1. Right click a form link
2. Select “save target as”
3. This will open a window, which will present the option to save the file. (If you would like to save the file to your desktop, select “desktop”). Select “Save”.
4. Open a current version of Adobe Reader (a free download link is available at the bottom of the page if you do not have this program or it is outdated)
5. Open the form on your desktop in Adobe Reader, complete the form and select the “submit” button on the form. Once your form has been successfully submitted, you will receive a “Success” message in your web browser window.
MAC Users
1. Control click on a form link.
2. Select “Download Linked File As”
3. This will open a window, which will present the option to save the file. (If you would like to save the file to your desktop, select “desktop”). Select “Save”.
4. Open a current version of Adobe Reader (a free download link is available at the bottom of the page if you do not have this program or it is outdated)
5. Open the form on your desktop in Adobe Reader, complete the form and select the “submit” button on the form. Once your form has been successfully submitted, you will receive a “Success” message in your web browser window.