Patient Forms

Authorization for Disclosure
of Health Information

Incapacitated Patient Form

New Patient Packet 2023

Consent to Clinical Procedures 2023

NOPP Acknowledgement 2023

Patient Communications and Financial Policies 2023

To view these forms you’ll need Adobe reader. Download a free version here.

Premier Dermatology accepts all the following insurance plans:

  • Premier Dermatology Contracted Insurance
    • Advocate
    • Advocate Meridian FHP Medicaid HMO
    • Aetna
    • Beech Street I PPO Next PPO
    • Blue Cross Blue Shield
    • Blue Cross Medicare Advantage PPO
    • Blue Cross Community MMAI HMO (Medicare-Medicaid)
    • Cigna
    • First Health EPO & PPO
    • Cofinity PPO
    • Coventry HMO & PPO
    • Equian
    • Fox Valley Medicine
    • HealthNet PC3
    • Healthlink / Unicare PPO
    • HFN
    • Humana
    • Liberty Healthshare
    • Medicaid – Illinois
    • Medicare
    • MultiPlan HealthEOS PHCS
    • Presence Health
    • Railroad Medicare
    • SEIU - Local 4 HMO & PPO
    • Three Rivers Provider Network
    • Tricare – HealthNet
    • United Healthcare
    • Union Medical (Local 1546) HMO

Premier Dermatology recommends you contact your healthcare insurance provider prior to your appointment to confirm network status, benefits, and any required pre-authorizations prior to receiving care from a Premier Dermatology provider. For patients without certain types of health care coverage or who are not using certain types of health care coverage, an estimate of their bill for health care items and services before those items or services are provided. This is known as a Good Faith Estimate.