Patient Forms & Express Check-in

Please follow the steps below and click on the links highlighted in blue to access the forms.

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 stating you have received a copy of the HIPAA policy.
  3. Print HIPAA POLICYthis is for your records only. It is not necessary for you to bring it 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. Print, initial, sign and date the GUARANTOR BILLING AGREEMENT. This is an agreement between the patient and Summit Skin and Vein Care.
  6. Copy of driver’s license
  7. 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
  2. E-mail all of the above documents to:
  3. Mail to us at: 3521 NE Ralph Powell Rd, Ste C, Lee’s Summit, MO  64064

3rd STEP

  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 10 minutes prior to appointment to:

  1. Check-in
  2. Sign any additional paperwork
  3. Make payment for copay, coinsurance and / or deductible


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