Patient Forms 

New Patient Forms
​Consent for Medical Treatment of a  Minor
Notice of Privacy Practices
Medical Record Release Form

Patient Registration and Information:

Our doctors and staff are dedicated to providing you with an exceptional visit and care that enhances your skin's health. Our administrative staff is available to answer questions about scheduling and insurance. Please check the directory to email your questions.

New Patients:

New patients will be asked to complete our medical history and patient registration forms.  You may download and print these forms and complete them prior to your visit; alternatively, please arrive 15 minutes early and complete them at the time of your visit. For insurance purposes, you are considered a "New Patient" if we have not seen you in the past three years. You will be asked to fill out the New Patient forms and we will need to register and verify all your information again.
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In order to expedite your visit, click on the patient forms button below to download, print, and fill out the forms prior to your visit. For our new patients: please note that it will take approximately 20-30 minutes to register you in our computer system and to verify your insurance and information. Thank you for your patience in this matter. ​

Children Under 18

IMPORTANT: A parent or guardian must accompany all patients under 18 to a first visit to our clinic, as well as to any visit where we may consider prescribing oral medication or performing any procedures. In the case that your are unable to come with your child, you may print and sign the Consent for Medical Treatment of a Minor and bring this form to the appointment.

Please bring the following when you come to your appointment at El Centro Dermatology:

• Your medical insurance card
• Medication benefits card 
• Photo identification card
• Payment for any co-pays
• Your referral paper and any labs or imaging, if applicable
• A list of medications you are presently taking and any that you have used previously for your skin condition

Insurances that we accept

El Centro Dermatology is contracted with over 80 of the major health insurance companies in Imperial County. The following is a partial list of health insurance plans we currently accept:

• AARP Medicare
• Aetna
• Blue Cross
• Blue Shield
• California Health and Wellness (you will need a referral from your primary care provider prior to being seen)**
• CHAMP VA HAC
• Christian Borthers Services
• Cigna
• Commonity Care IPA
• Easy Access IPA (you will need a referral from your primary care provider prior to being seen)**
• EZ Care MSO LLC (you will need a referral from your primary care provider prior to being seen)**
• EBMS (Employee Benefit Management Services)
• Employee Benefit Consultants, Inc.
• GEHA-ASA
• Health Comp
• Health Net California (Dr. Dang only)
• Health West TPA
• HealthPartners
• HumanaCare Plan
• Kaiser Foundation Health Plan of Southern CA 
• Key Solution
• Imperial County Physician's Medical Group - ICPMG (you will need a referral prior to being seen)**
• Medicaid of California
• Medi-Cal
• Medicare
• Medpoint CCI (you will need a referral from your primary care provider prior to being seen)**
• Molina Health Care (you will need a referral from your primary care provider prior to being seen)**
• Palmetto GBA-RR Medicare Part B
• Premier Care IPA
• S CA Medicare
• Tricare for Life
• Triwest
• United Life Insurance Company
• United Healthcare
• Veterans Community Care Network
• Western Growers/Pinnacle Claims

​As changes may occur in the plans that we accept, please verify our acceptance of your insurance at the time you make an appointment. Even though your insurance may not be shown on our list, you may call our office at 760-337-8500 to see if it is currently accepted.

**Please note that all HMOs require a referral from your primary care provider prior to being seen.

Terms of payments

Payments of all copays, deductibles, and/or coinsurance are due at the time of service. As a service to you, our office will bill your insurance company. Being a participating provider with most insurance companies, the insurance companies require that we collect these fees, as they are terms of your health care contract. Additionally, patients are ultimately responsible for all balances.

For your convenience, we accept credit cards including Visa, MasterCard, Discover, and Debit Cards. We offer payment plans through Cherry and Care Credit for cosmetic procedures. 

Due to the constant changes in health insurance it is your responsibility to know your health coverage. If you should have any questions regarding if a certain procedure is covered, it is to your advantage to call your insurance company and find out exactly what your contract covers. Their customer service representatives will be happy to assist you.

Appointment Cancellations

​Please call, text, or email us 24 hours in advance or as soon as possible if you are unable to keep your appointment. 

Payment Plans

At El Centro Dermatology & Laser Center, our staff will work to help you achieve your cosmetic goals in a way that will match your budget. For those who wish to finance their procedures, our office has relationships with several companies that specialize in medical financing. You apply just as you would for other kinds of credit, and make scheduled payments. Our office staff has extensive experience in this area and will be happy to assist you in your choice of financing, as well as your application.
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You can explore the links below to learn more about financing for your cosmetic procedure or you can request a free cosmetic consultation online or call the office at 760-337-8500 and we would be happy to assist you with the application process.
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Apply for Care Credit
Apply for Cherry

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