forms

If you are a new patient to the Dermatology Division of Longevity Physician Specialists, please print out and complete the New Patient Forms below to expedite your visit.

Please BE SURE to also bring your DRIVER’s LICENSE and INSURANCE CARD with you as well. This information is required at the time of your visit so that we are able to verify your insurance benefits. All benefit information received from your insurance company is only a quote of benefits. Patients are responsible for any services that are not covered by their insurance policy.

Patient Information Form and Office Policies

Medical History Form

Incoming_records_release_form

Outbound_records_release_form

HRA_and_HSA_Policy

HIPAA_Form

Forms of Payment:
We accept Visa, MasterCard, Discover, CareCredit, Checks, Cash and CareCredit.