PHYSICIAN APPOINTMENT FORMS

Please print and complete the following forms and bring to your appointment, along with your insurance card and photo identification.

 

DPNS

 

We must have the insured’s date of birth and social security number. If you do not wish to give out your social security number, please let us know. However, there are no exceptions for the date of birth of the insured.

 

We require this information in order to file claims in a timely manner.

We participate in the following plans:

  • Aetna

  • Beech Street PPO

  • Blue Cross/Blue Shield PPO

  • Blue Choice

  • Blue Cross/Blue Shield HMO IL
    (site 447 & 284)

  • Cigna

  • First Health/Coventry

  • Great West

  • HFN

  • Humana

  • Medicare

  • PHCS/Multiplan PPO

  • Unicare/Healthlink PPO

  • United Healthcare

Prescription Refills

To request a prescription refill please contact your pharmacy and ask them to fax us a refill request to (847) 272-4434 or send it electronically.

For products purchased in our office please call our office at (847) 272-4433.

© 2018 Dermatology Partners of North Shore, LLC. All rights reserved