Forms and Policies

NEW PATIENT PAPERWORK:

Kittridge Dermatology New Patient Packet

TELDERMATOLOGY CONSENT:

Kittridge Dermatology Teledermatology Consent

HEALTH INSURANCE REIMBURSEMENT/CLAIMS FORMS:

Kittridge Dermatology makes no representation that your claim will be reimbursed partially or in its entirety. For privately insured patients, upon request, we can provide the necessary information for you via a coded superbill to file a claim with your insurance company (there is a small charge to cover the physician’s time). Additionally, you will need to print and complete the appropriate reimbursement form and submit to your insurance. To make this process easy and simple, we have provided the claims forms for the most common insurance companies below. If you do not see the appropriate form for your insurance you may use the Universal Health Insurance Claim Form and should contact your insurance to make sure no other specific form needs to be completed. All questions regarding your insurance coverage and reimbursement should be directed toward your insurance company or benefits manager.

Please note that by law Medicare and Medicaid patients cannot submit for reimbursement.

UPMC HEALTHCARE Claim Form

Highmark BCBS Healthcare Claim Form

United Healthcare Claim Form

United Healthcare How To Submit A Claim

Aetna Healthcare Claim Form

Universal Health Insurance Claim Form

OTHER FORMS:

Medical Records Release Form

Authorization to Treat Minors

POLICIES:

Scheduling & Financial Policies