Forms and Policies

Before your visit with us, please complete our Patient Registration Form here.

General Scheduling Policies 

Please bring the following items with you to each appointment:

  • Driver’s License / Photo ID
  • Health Insurance Card(s)
  • Method of Payment
  • Medication List
  • Please inform the receptionist of any demographic changes: phone number, address, etc.
  • Scheduling for surgical appointments must be made via phone or in-person.
  • No-show. Appointments missed without 24-hour notice will result in a $100 charge. One exception to this is an emergency and these are determined on a case-by-case basis at the discretion of our office.
  • Medical dermatology appointments are either 15 minute or 30 minute visits. All new patients will be scheduled for an initial 30 minute appointment.
  • Surgical appointments are based on 20 minute increments based on surgical complexity. Please refer to the medical dermatology and surgical dermatology pages on our website for specific pricing of services.
  • Maine Direct Dermatology uses online scheduling system which can be found at
  • Please select the Full Body Skin Exam appointment if you have multiple concerns that you would like to address during your visit.
  • If your concern is not listed or if you are unclear which appointment to select, please call us at 207-360-4214 to schedule.

Private Insurance/Self Pay/ No Insurance:

  • Maine Direct  Dermatology does not participate and is considered out of network with private health insurance.
  • Patients pay Maine Direct Dermatology directly for the care they receive at the time of service. Fee schedules for medical and surgical services are posted on our website under the “Pricing” section.
  • Occasionally, there may be an additional fee for staff time, administrative work, or other extra tasks that are done on your behalf. We will inform you BEFOREHAND if extra fees are involved. An example would be the time spent by the physician to process a prior authorization for prescriptions ($25).
  • Fees are subject to change at any time without notice.


  • Payment in full is required at the time services are rendered for charges that are your responsibility. 
  • Cash and credit cards are accepted forms of payment. A credit card on file is required to book some appointments but is not charged unless our cancellation policy is violated. In some instances, a deposit must be collected to reserve your appointment. You will be notified beforehand if this is the case.
  • HSA/FSA. Health spending (HSA) and flex spending (FSA) accounts are accepted for all medically necessary services.
  • JaneApp, and Other Credit Card Processing. We use JaneApp for online payment, analytics, and other business services.
  • We require a credit card to be on file via our secure credit card processing company at the time of scheduling.
  • You can learn more about JaneApp and read their privacy policy at

Cosmetic/ Aesthetician/ Elective Procedures

  • These services are billed under a separate fee schedule. As always, payment is due at the time of service. Some procedures may require a deposit before services are rendered. We will not charge your card without first discussing your charges with you.

Lab and Pathology Fees

  • We have negotiated discounted fees for pathology of $75 per specimen, or you may choose to use your private health insurance to submit a claim for each specimen.
  • Any service(s) provided by a lab or hospital is a contract between you, and that lab or hospital and should be handled with that lab or hospital. It is not the responsibility of our practice.
  • It is your responsibility to know which procedures your insurance will and will not cover at these facilities and to request an Explanation of Benefits (EOB) from your insurance carrier.

No-show and Cancellation Fee

  • We require a 24-hour notice for cancellation. Kindly follow the instructions for cancellations for our online scheduling system or call us to cancel/reschedule as necessary.
  • Missed visits without 24-hour notice will result in charge of $100.00 fee.
  • Exceptions to the cancellation policy are made for emergencies and decided on a case-by-case basis at the discretion of Maine Direct Dermatology.

Ways In Which We May Use And Disclose Your Protected Health Information:

Appointment Reminders. We will use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment.

Treatment Alternatives. We will use and disclose your protected health information to tell you about or to recommend possible alternative treatments or options that may be of interest to you.

Others Involved In Your Care. We will use and disclose your protected health information to a family member, relative, a close friend, or any other person you identify that is involved in your medical care or payment for care only if we have received explicit permission from you.

As Required By Law. We will use and disclose your protected health information when required by federal, state, or local law. You will be notified of any such disclosures.

To Avert A Serious Threat To Public Health Or Safety. We will use and disclose your protected health information to a public health authority that is permitted to collect or receive information to control disease, injury, or disability. If directed by the health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority.

Workers Compensation. We will use and disclose your protected health information for Worker's Compensation or similar programs that provide benefits for work-related injuries or illness.

Inmates. We will use disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law-enforcement official. This information would be necessary for the institution to provide you with health care; to protect the health and safety of others; or for the safety and security of the correctional institution.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have a right to:

A Paper Copy Of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit or by visiting our website.

Inspect And Copy. You have the right to inspect and copy the protected health information that we maintain about you and our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. Any psychotherapy notes that may have been included in the records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

Request Amendment. You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and the reasoning that supports your request.

We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if:

  • The information was not created by us, or the person who created it is no longer available to make an amendment;
  • The information is not part of the record which you are permitted to inspect and copy;
  • The information is not part of the designated records that kept by this practice;
  • If it is the opinion of the healthcare physician that the information is not accurate or complete.

Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your medical information for treatment, payment, or healthcare operations. For example, – you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be made in writing.

We are not required to agree to your request if we feel it is in your best interest to use or disclose that information. However, if we do agree, we will comply with your request unless that information is needed for emergency treatment.

An Accounting Of Disclosures. You have the right to request a list of the disclosures of your health information we have made outside our practice that were not for treatment, payment, or healthcare operations. Your request must be made in writing and my state the time for the requested information. You may not request information for any dates before April 14, 2003 (the compliance date for the federal regulation) nor for a period of time greater than six years (our legal obligation to retain information).

Your first request for a list of disclosures within 12 months will be free. If you request an additional list within 12 months of the initial request, we may charge you a fee for the cost of providing the following list. We will notify you of such cost and allow you to withdraw your request before any costs are incurred.

Request Confidential Communications. You have the right to request how we communicate with you to preserve your privacy. For example – you may request that we call you only at your work number or by email. Your request must be made in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests.

File A Complaint. If you believe we have violated your medical information privacy rights, you have a right to file a complaint with our practice manager or directly to the Secretary of Health and Human Services.

Use Or Disclosures Not Covered

Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such consent in writing at any time, and we no longer disclose health information about you for the reasons stated in your written authorization. Disclosures made in reliance on the consent before the revocation are not affected by the revocation.

For More Information

If you have questions or would like additional information, you may contact our office at (207)-360-4214.

Effective Date: December 1, 2023.