Download the Patient Forms

Please follow the steps below and use the links on the left for the
New Patient "EXPRESS" Check-in

The following steps need to be completed 48 hours in advance of your appointment time.

1st STEP
1) Print, complete and sign PHOTO CONSENT
2) Print HIPAA ACKNOWLEDGMENT - please complete and sign top portion of HIPAA Acknowledgement if you want a copy of the HIPAA policy or complete and sign the bottom portion of HIPAA Acknowledgment if you are declining a copy of the HIPAA policy
3) Print HIPAA POLICY, if applicable - this is for your records only. It is not necessary for you to bring with you to our office or send back to our office.
4) Print AUTHORIZATION TO RELEASE HEALTH INFORMATION - please list anyone on this form that might come with you to our office as well as the physician you would like our doctor to correspond with
5) Copy of driver's license
6) Copy the front and back of your insurance card(s) - please verify that the "copy" of your insurance cards are legible before sending to our office.

2nd STEP
1) Fax all of the above documents to (816) 554-9470
                              OR
2) E-mail all of the above documents to: newpatient@summitskinandveincare.com
                                OR
3) Mail to us at: 3521 NE Ralph Powell Rd, Ste C, Lee's Summit, MO  64064
                             
3rd STEP
1) Go to PATIENT PORTAL
2) Complete demographics
3) Complete insurance information
4) Complete Medical History
Note: The information from the Patient Portal will be reviewed at the time of your appointment.

4th STEP
Arrive 5 minutes prior to appointment to:
1) Check-in
2) Sign insurance waiver
3) Pay copay, if required