Thank you for being our patient.

We are honored you have selected Advanced Dermatology & Skin Cancer Center, PLLC to be the dermatology provider for you and your family.

The following patient forms can be downloaded and printed at home. By filling out these forms ahead of time, you will save time during your visit. Please be prepared to provide this forms to our office along with your current medical insurance information and identification. If you have any questions when filling out these forms, our staff can assist you with your questions on the day of your appointment.

If you are a new patient, please print and complete the forms below to bring to your appointment:

New Patient Forms

Advanced Dermatology & Skin Cancer Center, PLLC is dedicated to providing the highest quality care for our patients in a timely and efficient manner. In an effort to maintain that efficiency, we attempt to contact every patient at least 24 hours prior to their appointment as a courtesy reminder. However, it is the responsibility of the patient to arrive on time for their appointment.

Cancellation/No Show Policy
If you are unable to keep your appointment, please provide our office a minimum of a 24 business hour notice. We do our best to notify every patient to try to confirm your appointment. There will be a $100.00 fee if you fail to keep the clinic/surgery appointment without the 24 business hour prior notification. If you cancel your Monday appointment on Saturday or Sunday you will still be charged the no-show fee. Your insurance does not cover the fee for no-show visits – you are fully responsible for the no-show fee. The charge will need to be paid prior to rescheduling the appointment. For patients without insurance coverage, your payment is due at the time of service.

Cosmetic Procedures
Cosmetic procedures are to be paid on the date of service. Some procedures may require a payment in advance or a deposit. The balance will need to be paid on the day of service. You may call our office at 479-718-7546, select option 2 or extension 516. There will be a $100 charge for all cosmetic appointments that are not canceled at least 24 in advance to the appointment.

Surgery Payments
Prior to your surgery, the billing staff will verify your benefits. They will call/mail you a letter explaining your responsibility according to the benefits quoted by your insurance company. A surgery deposit will be required five (5) business days before your scheduled surgery date. If you have a delinquent balance on your account, it will need to be paid before you can make an appointment.

Pathology
If you have a biopsy and require a pathology report, there will be a separate bill. Once a diagnosis has been determined and a Pathology report has been received in our clinic, your charges are billed to your account. Your statement may be from our office/outside pathology office, depending on your diagnosis.

Products
Any product is to be paid on the date of purchase. All product sales are FINAL; No returns or exchanges are allowed.

Advanced Dermatology & Skin Cancer Center, PLLC, downloadable policy documents:

ADSCC Financial Policy and Privacy Practices

Online Bill Pay

For your convenience, we also offer online bill pay. Please enter the amount you wish to pay in the box below and click “Click to Proceed” to go to the next step. In the next step, you will enter your Customer ID number and additional information.

Your Customer ID is your Account Number on your statement. If you are pre-paying for a surgery, please call (479) 718-7546 ext. 517.

Thank you for your payment.

Once you enter the amount you wish to pay, click the button “CLICK TO PROCEED” to be redirected to our payment processing page to complete the transaction and ensure it is properly attached to your account.
*NOTE: You will enter your Account Number in the “Customer ID” field on the payment processing page.