Patient Information

New Patient Forms

For your convenience, please fill out the following forms and bring them to your appointment:

Patient Information Sheet

Patient Medical History

Medicare One Time Authorization

(The Medicare One Time Authorization is required for patients with Medicare Part B coverage.) 

Medicare Secondary Payer Questionnaire

(The Medicare Secondary Payer Questionnaire is required for patients with Medicare Part B coverage.)

 

Free Acrobat Reader is needed to view the forms. You can download it here.

Insurances Accepted

South Lincoln Dermatology Clinic accepts most major medical insurance plans including Medicaid and Medicare.

Note:  Dr Weir is not an in network provider for CHI (Catholic Health Initiative).  The rest of our providers are.

Payment Information

We accept Cash, Check and all major credit cards. You can also securely pay online using the button below.

Pay Online