Copayments and most deductibles are due at the time of your in-person or telemedicine visit.
You can pay with credit card (surcharge of 3.95% will be applied)
You also have an option to pay via Zelle (payable to | Dr. Avshalumova
Patient Registration Form

Patient Information


Contact Information

Payment Information

Is your insurance active? *
Are you a primary insurance holder? *
Does your insurance require a referral from your Primary Care Provider? Metroplus and Fidelis Medicaid plans REQUIRE referrals. *

Pharmacy Information


Care Team

Next of kin

Current Medications


Do you have any allergies? *

Past Medical History

Family Medical History

Lifestyle Factors

Have you ever smoked ? *
Do you smoke now? *

Reason For Consultation?

No Show / Cancellation Policy

The providers at 212SKIN AL Dermatology PC strive to see all patients in the most timely and convenient manner possible.  As a courtesy, we attempt to contact every patient at least 48 hours prior to their scheduled appointment to remind them of the date and time.  It is the responsibility of the patient to arrive for their appointment on time. 

If you are unable to keep your appointment, we ask that you call our office at least 24 hours in advance so that we may offer this time to another patient in need of care.

The no show/cancellation policy has been established to help us serve you better. 

No-shows and last minute cancellations cause problems that go beyond a financial impact on our practice.

No-shows and late-cancellations delay the delivery of health care to other patients.

A “no-show” is missing a scheduled appointment.   A “late- cancellation” is cancelling an appointment without calling us to cancel 24 hours in advance of an office visit.

To cancel appointments, please call 212-674-777 or 212-729-SKIN(7546), at least 24 hours in advance to the scheduled appointment time, to avoid charge of a no-show/cancellation fee.

If you do not reach the receptionist, you may leave a detailed message, including your name and phone number, on the voice mail.

Any cancellations made within the last 24 hours prior to the appointment time, will result in a fee of $50 for medical services and $150 for cosmetic services.  

We understand that situations such as medical emergencies occasionally arise when an appointment cannot be kept and adequate notice is not possible. These situations will be considered on a case by case basis. 

Cancellations made more than 24 hours in advance of your scheduled appointment time will not be assessed a cancellation fee.

A "no-show" is someone who misses an appointment without calling 24 hours in advance to cancel.

"No-shows" inconvenience those individuals who need access to medical care in a timely manner, as well as the physician.   A failure to show up at the time of a scheduled appointment will be recorded in the patient's chart as a "no-show".

 Any "no shows" will result in a fee of $50 for medical services and $150.00 for cosmetic services.

Please understand that insurance companies consider the no show/cancellation fee charge to be entirely the patient’s responsibility.

By signing this form you affirm that you understand the terms of the No show/Cancellation Policy

set forth by 212SKIN AL Dermatology PC and that you authorize 212SKIN AL Dermatology PC to assess cancellation and no show fees according to the above outlined policy to the credit card listed below.

Copayments and most deductibles are due at the time of your in-person or telemedicine visit.
You can pay with credit card (surcharge of 3.95% will be applied)
You also have an option to pay via Zelle (payable to 

Signature. (Non-Touchscreen just enter your name)


HIPAA Notice of Information Practice

This notice describes how medical information about you may be disclosed.

AL Dermatology PC will use your medical information for the following: Please review it carefully.


TREATMENT: Including providing your medical records to consulting clinicians and insurance companies.

PAYMENT: We will file necessary claims to insurance companies in your name to obtain payment.

They may request part or all of your medical records to pay the claim.

HEALTH CARE OPERATIONS: Any other involved in your healthcare.


Protecting the privacy of your personal health information is important to us. This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, and public health, research, and law enforcement activities. Any other disclosures for the purpose of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on disclosures. Disclosures of protected health information are limited to the minimum necessary for the purpose of the disclosure. This provision does not apply to the transfer of medical records for treatment. You may inspect and receive copies of your records within 30 days after requesting to do so. There may be a reasonable cost-based fee for photocopying, postage, and preparation. You may request changes to your records. Our practice has the right to accept or deny your request. We maintain a history of protected health information disclosures that are accessible to you. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice. Our practice is required to abide by this notice. We have the right to change this notice in the future. Any revisions will be prominently displayed in a clearly visible location in our office.

**The entire PRIVATE POLICY NOTICE of AL Dermatology PC is posted in the waiting room for your perusal**

Email DisclaimerThe information contained in the practices transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. Please check box if you agree for email communication with Doctor and Staff


I hereby acknowledge receipt of the Notice of Privacy Practices for Dr. Lyubov Avshalumova regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Dr. Lyubov Avshalumova.

Signature. (Non-Touchscreen just enter your name) *

Financial Policy

Welcome to AL Dermatology PC. We are dedicated to providing you with the highest level of medical care in a compassionate and proficient manner. All patients are expected to complete a patient financial responsibility form annually. You will need to read carefully the Financial Policies as described below.

Your co-payment will be collected on the date of service. Any deductible, co-insurance, or full payment is due at the time services are rendered. We cannot waive co-payments, deductibles, co-insurance or non-covered service amounts defined as patient responsibility under the terms of our contract with various health plans.

For your convenience we accept cash, money orders, most major credit cards, personal checks and PayPal as an extended payment option. If you cannot provide a current medical insurance card, full payment must be made at the time services are rendered. It is your obligation to make certain that this office is a participating provider of your policy and that referral information and authorization has been obtained in advance of your appointment. We will file your insurance claims for you if all necessary information is received at the time of your visit. It is also your responsibility to inform our office of changes in insurance coverage and/or personal contact information.

If payment is not received from your insurance company within 45 days, you will be billed for the services rendered. You will also be billed for any services not covered by your insurance                                                                                                                                                                                                                                        company. An account for which no payment is received within 60 days and for which no payment arrangements are made may be sent to a collection agency. The balance will accrue a monthly interest fee and an additional fee for the expenses related to collections. Checks returned to our office for non-sufficient funds (NSF) will incur a $30 service charge.

Patients are seen by appointment. If you cannot keep your appointment it is your responsibility to call at least 24 hours in advance. We do understand that occasionally it will be necessary to change or cancel an appointment in less than 24 hours; however, if an appointment is missed without the required notice there will be a $50 charge for medical services and a $150 fee charge for cosmetic services.


We try to utilize contracted laboratories for biopsies. When skin growths are biopsied or removed, there are two separate charges. Charge for the actual biopsy/removal performed and lab charge for preparing and examining specimen slides under a microscope. Lab charges occur on a different date. If the specimen slides require a second opinion or special stain, an independent lab (not owned by our practice) will bill your insurance carrier for additional fees. If you have questions about these additional lab fees, please contact the lab directly as these fees are not charged by our office.

Unaccompanied minors must have a consent signed by a parent or guardian. Non-emergency treatment will be denied unless non-covered charges and co-pays have been paid and insurance billing is approved under the insured’s policy. Co-pays and other charges can be paid via telephone by credit card.

Should you request copies of your medical records, there is a fee charged as allowed by current NYS statutes. There is also a cost associated with your request for physician “narrative reports” and/or letters not related to our insurance claims. These fees would be based on the complexity and amount of time involved.


I have read and understand the terms of this Financial Policy. I understand and agree that such terms may be amended from time to time by the practice. I agree to assign insurance benefits to AL Dermatology PC. I authorize the release of medical information to my primary care or referring physician, and/or consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions.

By signing this form I authorize 212SKIN AL Dermatology PC to assess applicable fees according to the above outlined policies to the credit card listed on my file.

Signature. (Non-Touchscreen just enter your name) *
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