New Patients and Forms

our first visit to Phoebe Rich Dermatology establishes a crucial foundation for our relationship with you. During the initial visit, we obtain your medical history and any other information that may be pertinent to maximizing the benefits of your visit.

During this first visit, you will begin by checking in with one of our receptionists; please bring in your insurance card, an ID card, and a current medication list. Once you have completed your paperwork, one of our medical assistants will bring you back to an examination room where they will review your paperwork, your previous dermatologic history, and your current dermatologic concerns (the reason you've scheduled your visit). After noting this information in your electronic file, they will leave the examination room and leave you to change into a medical gown. While you're changing, they are presenting your information to the provider. When the provider arrives in your exam room, the medical assistant will also be with them so they can scribe for the provider. This allows the provider to give you (and your skin) their undivided attention while the medical assistant takes down all locations and descriptions into your electronic medical chart. Should medications be prescribed, we will do our best to send these to your pharmacy electronically. If time allows, we also aim to do small procedures at the same appointment.

Below you will find directions, office hours, and links to new patient paperwork. To save you time before your first visit, you can print out our paperwork and bring the completed forms with you to your appointment. If you'd prefer to fill out t

Mission Statement
Our practice is working together to realize a shared vision of uncompromising excellence in dermatology.

To fulfill this mission, we are committed to:

• Listening to those we are privileged to serve
• Earning the trust and respect of patients, professionals and community
• Exceeding your expectations
• Ensuring a creative, challenging, and compassionate professional environment
• Striving for continuous improvement at all levels

Patient Forms & Preparing for Your Visit
All new patients are required to fill out the Patient Registration, Health History, Notice of Privay Practices Acknowledgment, and Genetic Testing Participation forms. Depending on what issues you are being seen for, you may also be required to fill out the forms that relate to the specific reason for your visit.

If you are a returning patient, but have not had an appointment within 3 or more years, we ask that you please fill out a new Health History form and bring it with you to your visit. In addition to completed paperwork, feel free to bring anything else you think might help your provider better understand your concerns. This includes, but is not limited to, additional health histories, chart notes, and a list of any medications or topical treatments that you may be using at the time.

If you are coming in for the following, please be be aware:

• Acne - please arrive with no makeup
• Rash - make sure to bring in a current medication list
• Nails - please arrive with no nail polish or acrylics on your nails

Click the links below to download our required forms:

• Patient Registration
• Health History
• Notice of Privacy Practices
• Notice of Privacy Practices (Spanish)
• Notice of Privacy Practices Acknowledgment
• Genetic Testing Participation

Please also complete ONE of the following forms ONLY if it pertains to the reason for your visit:

• Acne History
• Hair Loss History
• Dermatitis (Eczema, Rash) History
• Nail History
• Psoriasis History
• Hyperhidrosis Evaluation

Additional Forms:

• Financial Policy
• Records Request (sending records from our office)
• Records Request (sending records to our office)

In order to view or print these forms you will need to have Adobe Acrobat Reader installed. Click the link below to download and install: Download Adobe Acrobat Reader

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

Under the law, health care providers need to give patients who don’t health insurance or who are choosing to be self-pay an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.
• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health Edited 2/22 care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email [email protected], or call 1- 800-985-3059.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

Map and Directions
We are located near the corner of 25th and NW Lovejoy St., close to the NW 23rd Shopping District. Our office is in the upper level of a small brick building right off of Lovejoy St., in Suite 200. We have a parking lot next to our building.