Appointment Request Est This request form is only for patients who had an appointment with us in the past and want to update their information (eg. insurance, address, phone etc.). If we have not seen you before then please click here to fill out the appointment request for new patients. If we have seen you before and your information has not changed in the last few months then please just email us at appointments@rdmaui.com for a new appointment for faster service. Previous Next Demographics: Your Name My Name changed Provide above the name you used at your last visit and below your new name. Date of Birth Address Email Phone Number Did your insurance information change since we saw you last? YesNo Please select your new insurance information below. If your insurance is not listed, we can still see you but you will be expected to pay out-of-pocket. Please Note: We do not accept any Medicare Advantage plans or Medicaid plans (Quest) unless they are administered by HMSA. —Please choose an option—Out-of-Pocket (no insurance)HMSA PPOHMSA HMOHMSA QuestHMSA Akamai Advantage PlanMedicare (direct, NOT a Medicare Advantage Plan)TriCare (Military)Veterans Administration (VA)HMAABlueCross® BlueShield®HMAUHAPSWA You selected an insurance plan that requires a referral. Please note that without a referral from your Primary Care Provider (PCP) your insurance will deny coverage and you will end up paying out-of-pocket. Please contact your PCP and have them issue a referral to Reisenauer Dermatology. We call you and schedule an appointment as soon as we receive it. Please take images of your insurance cards or upload PDFs. Alternatively, you can also just provide the member number/ID manually in the field below. Primary Coverage (front and back): ...or type member number/ID: Secondary Coverage (front and back): ...or type member number/ID: Previous Next Your information will be securely sent to and stored in Google Sheets for the purpose of processing your form submission.
