In addition, parents who are bringing in a minor will also need the following forms. Teenagers may be treated without the parent’s attendance ONLY if the following documents are brought with the patient.
Note: These forms are standard for every new patient visit and in some cases returning patients. Every appointment is different and additional consent forms/paperwork may be required before the completions of certain procedures including, but not limited to: laser treatments, photofacials, microdermabrasions, fillers, and vein therapy.
These files are in PDF format. If you do not have Adobe® Reader® on your computer, you can download it for free by clicking here or on the Get Adobe Reader icon.
Cosmetic consultation fee is due at the time of your consultation appointment. This cosmetic consultation fee will not apply towards future cosmetic services. This cosmetic consultation fee only applies to cosmetic consultations, for medical estimates, please contact our Billing Department.
NO SHOW/CANCELLATION POLICY
The providers at Vail | Aspen | Breckenridge | Glenwood Dermatology strive to see all our patients in the most timely and convenient manner possible. As a courtesy, we attempt to contact every patient at least 24 to 48 hours prior to their scheduled appointment to remind them of the date and time. However, it is the responsibility of the patient to arrive for their appointment on time. If you are unable to keep your appointment, we ask that you call our office at least 24 hours in advance so that we may offer this time to another patient in need of care. We currently have a lengthy waiting list for both new and established patients.
No Show Policy No show/late cancellation fee will be charged to any established patient who does not give a 24-hour notice to cancel appointment. Exception will be given to patients who no show due to bad weather, natural disaster, illness, or death of a loved one. Fees are listed below. New patients will not be charged a no-show fee unless the patient was notified prior to the appointment as they have not established doctor/patient relationship. Medicaid and TriWest are examples of insurance where no shows fees are not allowed. Should a patient dispute the fee, staff has the right to waive the first fee as a courtesy. However, fees will apply to any future incidents. If a patient has multiple no-show appointments, the clinic has the right to discontinue scheduling the patient. Fees: $35 for Medical Visits $75 for Surgeries and Cosmetic visits Aesthetic Service Fees: For patients that do not contact us prior to missing their cosmetic appointment (at least 24 hours in advance) will be regarded as “no show” and charged for the service scheduled, up to $200:
Services up to $100 will be charged a $50 no show fee.
Services up to $100-$250 will be charged a $75 no show fee.
Services above $250 will be charged a $200 no show fee.
Coolsculpting appointments require a $1500 deposit at the time of booking.
Treatment totals of $1500 must be paid in full at the time of booking.
PRODUCT RETURN POLICY
Products that are unused, unopened, and in original packaging are eligible for a full refund up to 30 days after the date of purchase and may be eligible for a credit or exchange up to 60 days after the date of purchase. Open or used products cannot be returned or exchanged excluding the following instances:
Reaction to product:
Upon doctor confirmation of skin reaction, used products are eligible for a full refund.
Defective packaging:
Opened products with defective packaging can be replaced with the same item for up to 30 days from the date of purchase.
ACCEPTED INSURANCES
Aetna/Cofinity PPO
Anthem Blue Cross & Blue Shield (contact BCBS, we are not in-network with all plans)
Bright Health PPO
Great West/CIGNA PPO
Humana/Choicecare PPO & Medicare Advantage
Kaiser Permanente (Mountain Colorado plans and PPO-referrals required for some PPO’s)
Liberty HealthShare
Medicare
Medicare Railroad
MultiPlan/PHCS
Rocky Mountain Health Plans PPO & HMO (includes Medicare Replacement & CHP+) Exclusions: Rocky Mountain Range, New West, (CSHP) Colorado Springs, Mesa Exclusive and Medicaid.
The Colorado Health Neighborhood PPO
The Empire Plan of New York (only certain providers)
Tricare
United Healthcare PPO (Some plans require a referral. PCP has to enter a referral online with UHC)
VA – Must have authorization
Valley View Hospital
Please note: We are out-of-network with Medicare HMO Advantage Plans except Humana and RMHP. We are out-of-network with EPO plans We do not see Medicaid patients. We are a specialist and not considered preventative with most insurances.
PAYMENT OPTIONS
American Express, MasterCard, Visa, Discover, Cash, and Checks.
Please rest assured that all information provided is kept confidential, secure, and HIPAA compliant. Please call the office at (970) 926-9226 if you have any questions.
Please Note: If you have a cosmetic procedure credit, your medical balance will not be accurate. Call the office for current balance or pay the amount listed on your statement.
How to Pay Your Online Bill:
1. Select the MyBillPay Dropdown 2. Select Online Bill Pay 3. Fill our payment information 4. Submit Payment
NEED MORE HELP? Try these tips!
Your first name – James not Jimmy, William not Bill? What name did you give the office when you called – what’s listed on your insurance card or driver’s license?
Security Code? You must call our office to get your unique security code.
Still need assistance? Call us at (970) 926-9226.
BILLING DEPARTMENT
For payments and insurance questions please call our billing department at (970) 926-9226 Option 3
For estimates, please call (970) 926-9226 ext. 310
