PATIENT FORMS

New Patient Packet– Please fill out all forms prior to your visit and bring with you to your visit.

Medical Records Release Request – Fill out this form if you would like us to request your medical records from your prior office.

Authorization to Treat Minors – If you are the parent/guardian of a new patient, then please fill out this form.

Medicare Agreement – RIDI does not participate with Medicare (see below).  If you currently have Medicare and would like to be seen at RIDI, please review and sign.

Official_Health_Insurance_Claim_Form – Fill out and submit to your insurance company if you would like to request reimbursement for your medical visit.  This applies to medical visits only and for non-medicare/medicaid patients.

OFFICE POLICIES

INSURANCE POLICY: RIDI does not participate with health insurance, and does not contract with Medicare or Medicaid. Due to government regulations, patients with Medicaid, Medicare, Medicare Supplements, Tricare or other government insurance programs can be seen for medical services but cannot be reimbursed by their insurance for services rendered at Rhode Island Dermatology Institute.

CANCELLATION POLICY:  In the interest of valuing everyone’s time, we require a 24-hour notice for cancellation. Kindly follow the instructions for cancellations for our online scheduling system or call us to cancel/reschedule as necessary. Missed visits without 24-hour notice will result in a charge of $100.00 fee. We require a credit card to be on file via our secure Square processing system. The credit card required for booking will NOT be charged unless there is a no-show or cancellation in less than 24 hours. You may pay for your appointment with cash, check or credit card at the time of your visit. Exceptions to the cancellation policy are made for emergencies and decided on a case-by-case basis at the discretion of Rhode Island Dermatology Institute.

PAYMENT POLICY: We accept cash, debit cards, check, Health Savings Account cards (HSA), Flex Spending Account cards (FSA), Visa, Mastercard, American Express and Discover.

PRIVACY POLICY: Please review the office Privacy Policies prior to your visit