We ask that you use the Patient Portal to remotely complete all of the required paperwork needed for your appointment. If you are unable to access the Patient Portal, please download and fill out forms and bring them with you to your appointment.
We appreciate your assistance with preparing for your appointment, and look forward to providing you the highest quality dermatological care. If you have any questions or concerns regarding the registration process, or any questions about your appointment, please do not hesitate to contact our office.
*If a patient is under the age of 18 and attending their appointment alone or with someone other than a parent or guardian please have a parent or guardian complete the following form and bring it with you to your appointment.
You can find the forms here: Patient Forms
Thank you for choosing Chicago Cosmetic Surgery and Dermatology as your dermatology care provider. Our primary mission is to provide our patients with outstanding medical care. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Carefully review the following information and return this form with your signature and today’s date. Please ask if you have any questions about our fees, our policies and/or your responsibilities.
To review the full financial policy please view our Financial Policy Form.
HIPAA AND NOTICE OF PRIVACY PRACTICES
At Chicago Cosmetic Surgery and Dermatology we strive to treat your medical information with the best care. We ask you to familiarize yourself with our privacy practices to understand your rights as well as our office’s obligations regarding your personal health information. You can find our HIPAA information here: CCSD HIPAA
If you fail to cancel your appointment prior to 24 hours of the time your appointment is scheduled or you miss your appointment, you may be subject to a fee.
Dermatology Appointment – $25 fee
Surgery, Cosmetic, Laser or Aesthetic Appointment – $50 fee
There is a $25 fee for any check returned for insufficient funds.
Please contact our office (312-245-9965 opt. 2) to schedule your appointment and to provide us with your up to date information.
You may also request an appointment through our patient portal, where you can also communicate with our office and view important documents. If you don’t have an account, call us and we’ll help you set one up.
We now offer requesting an appointment online! Once our patient entry staff confirm with you the appointment purpose and time, you’ll be confirmed and booked to come into the office!
WHERE DO I FIND PARKING?
- 10 E Grand (North Bridge parking garage) is located in the same building as the Hilton Garden Inn Hotel and the most accessible parking for our patients. We can offer up to 10 hours of parking validation at 10 E Grand for $9.
- Please note, we can no longer offer validation for the Grand Plaza Apartments parking.
- If you are considering taking an Uber or Lyft to our location, please ensure 515 N State st. is the pinned destination.
SHOULD I ARRIVE EARLY?
We recommend arriving 15 minutes prior to your first appointment so as to allow sufficient time for the registration process. If you would prefer to complete the forms at our office, please arrive 30 minutes prior to your appointment time.
WHAT TO BRING TO APPOINTMENT
Please be prepared to bring your pre-completed patient forms (unless you completed these forms via our portal) to our office along with your current medical insurance card and a government form photo identification. If your insurance requires a referral, please bring the referral form with you. For measures of security, during Saturday clinic hours, the desk staff at 515 N State St. will also require to see your photo identification when you enter the building – please have this ready to show them otherwise it may delay your appointment.
- All patient responsibilities (insurance) are due at the time of service.
- All self-pay/cosmetic (non-insurance) patients must pay at the time of service.
It is the patient’s responsibility to provide the clinic with current insurance information. Our relationship is with YOU, not your insurance provider. Please check with your insurance company to ensure our providers participate with your network. Failure to honor any agreements may result in your account being placed with a collection agency.
For an updated list of insurances we are in-network with (please note that this list can change often): in-network insurance list
If you are interested in financing any cosmetic procedures, please feel free to read about the financing options we have for our patients.
I AM INTERESTED IN COSMETIC PROCEDURES, WHERE DO I START?
Every person has different concerns about their appearance. We offer many different options to meet our patients’ needs. You can find the different cosmetic and procedures we offer through these links: Cosmetic | Procedures
You can also find skin care products on our store, Chicago Skin Science
To provide you with a customized treatment plan and financial quote, schedule a Cosmetic Consultation with our team of cosmetic dermatology experts! Call 312-245-9965 or book online.
WHAT IS THE PURPOSE OF A COSMETIC CONSULTATION?
Cosmetic Consultations are designed for our patients to receive cosmetic treatment and skincare recommendations based on a thorough assessment of the patient’s skin, goals, budget and unique needs. During the consultation we will obtain a patient’s health history and will perform a clinical evaluation of the skin to determine which treatment options are the best fit. We will customize both a treatment plan and skincare regimen. Important pre- and post-treatment instructions will also be provided to accompany most treatments.
HOW MUCH DO COSMETIC SERVICES COST?
Prices vary depending on the treatment, the areas treated and each patient’s specific goals. Accurate pricing is provided at your Cosmetic Consultation.
WHAT IS A PHYSICIAN ASSISTANT?
Physician Assistants (PAs) are health care professionals trained and licensed to practice medicine as delegated by and with the supervision of a physician. PAs are qualified by graduation from an accredited PA program and/or by the National Commission on Certification of Physician Assistants (NCCPA). In the health care setting, a PA can take a complete health history, perform physical exams, order diagnostic tests, prescribe most medications, diagnose and treat illnesses and injuries, provide patient education and preventive health care counseling. Along with handling most routine medical problems, PA’s can do more extensive procedures that fall within their specialties. The initials PA-C after their surname means the physician assistant is certified and has passed the certification exam developed jointly by the National Board of Medical Examiners and the NCCPA.
WHAT’S THE DIFFERENCE BETWEEN A DEDUCTIBLE, A COPAYMENT AND COINSURANCE?
All three are medical charges you must pay out of your own pocket, even if you have insurance. Deductibles are a specific amount you must accumulate and pay each year of covered health services before benefits are provided by your carrier. Plans may also have separate individual and family deductibles and/or deductibles for separate services. Copayments are a set fee the member pays to providers at the time services are provided. Copays are applied to office visits, emergency room visits, hospital admissions, etc. Coinsurance is a form of cost sharing. After your deductible has been met, plan will begin paying a percentage of your bills. The remaining amount, known as co-insurance, is the portion due by the patient.
WHAT IS THE PRODUCT RETURN POLICY?
We will accept returned, unopened product within 10 days of the purchase date.
We will not accept returns on any RX labeled products and Colorescience products.
WILL I RECEIVE A SEPARATE STATEMENT FOR MY LABS OR PATHOLOGY?
We have selected the physcians at Dermpath Lab of Central States to diagnose your skin biopsy. DLCS will bill your insurance directly for this service. Please call DLCS if any questions arise related to billing for your pathology lab service. Contact DLCS at 877-434-2351 or [email protected]
WHAT LANGUAGES ARE SPOKEN AT YOUR OFFICE?
The spoken languages at our facility among staff and/or physicians are Spanish, French, Arabic, Cantonese, Hindi, Greek, Serbian, and Macedonian. If you require assistance with translation please let us know in advance of your appointment so we can schedule you appropriately.