Patient Form

This form is only for patients of Dr. Asadi, Dr. Stern and Dr. Glaich. If you are a patient of any other DermSurgery doctor, please use our patient portal.

  • Contact Information

  • Employers Information

  • Primary Care Physician

  • Insurance Information

  • Emergency Contact Information

  • Notice to Managed Health Care Participants

    As a Managed Health Care patient it is YOUR RESPONSIBILITY to identify yourself as a PPO HMO or POS patient to our secretary EACH TIME you visit our office. If your POS or HMO plan required for you to obtain pre-authorization from your primary care physician or patient advocate,please provide our office with this information prior to your visit with the doctor, in order to obtain the highest level of benefits. If you fail to obtain prior authorization as directed by your plan you will be responsible for payment at the time services are rendered.

    I hereby authorize payment of insurance benefits to be paid directly to DermSurgery Associates / DSA Surgery Center for any services furnished to me. I authorize DermSurgery Associates to release information to Health Care Financing Administration and its agents, Medicare Champus, or any commercial insurance carrier covered by insurance or prepayment programs.