Bee Caves Dermatology - Dr. Mary Ann Martinez

■	Completed New Patient Information Packet
■	Current insurance card
■	Photo ID or Driver’s License
■	List of all current over the counter and prescription medicines
■	Form of payment for Co-Pay, Deductible or Fee for Service (cash, personal check, Visa, Mastercard, HSA debit card)

Forms:

■

New Patient Information Packet

■

Medical Release of Information Form -

To allow us to receive or send your records at your request.

■

Minor Consent Form -

For minors <18 years of age to be seen by the physician without a guardian present.

Accepted Insurances:

We are currently in- network providers for...

Blue Cross Blue Shield – PPO and HMO
Physicians Health Choice
Secure Horizons by United Healthcare - PFFS only
United Healthcare Medicare Direct - PFFS only
Humana Medicare Advantage Choice PPO
Humana Medicare Gold Choice PFFS
Medicare

Don't see your network?

We can still see you as a fee for service patient. Payment will be taken at the time of service. We will give you the paperwork and medical diagnosis codes for you to send to your insurance company so that you may receive your credit for your out of network deductible.

No health insurance?

We will see you fee for service and you will make payment directly to Bee Caves Dermatology at the time of service.

Out of Network Insurance or Out of Network HSA and Need to File on Your Own?

Click below for instructions on "How to File a Claim on Your Own".

■	Instructions on How to File a Claim on Your Own
■	HCFA 1500 Form

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Appointment Cancellations:

We ask that you give 24 hour notice if you must reschedule or cancel an appointment. If you fail to give 24 hour notice you will be assessed a $25.00 missed appointment fee.

Payments:

For in–network insurance companies, co-pays, deductibles and co-insurance amounts will be collected at the time of service.

Forms of Payment:

Cash
Personal check (we use Telecheck electronic checking)
Visa
MasterCard
HSA credit/debit card or HSA check

HSA / Health Savings Account?

We can see you and accept your HSA credit or debit card, check etc.

If we are in your network - Blue Cross Blue Shield - we can file the claim directly for you.

If we are not in your network you will be given the paperwork to file on your own to your HSA, but we may accept payment in the form of your HSA credit/debit card or HSA check.