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Aylesworth Dermatology

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Aylesworth Dermatology SC
550 E Timber Dr Ste 1
Rhinelander, WI 54501
Located in the Northwoods of Wisconsin
Fax: 715-226-9232
Please use the form to contact Aylesworth Dermatology. We will respond as soon as possible.

Patient Forms

Welcome to Dr. Aylesworths Office. Please send us your patient forms IN ADVANCE of your appointment in order to expedite your appointment time. To send us your patient/insurance information, and review our privacy policy, fill out the form below. If you have any questions, please give us a call at 715-226-9232.
At your appointment time, please have your INSURANCE CARDS with you as well as any CO-PAYMENT that you might have with your insurance company. If you are unable to keep your appointment, please call our office as soon as possible, preferably 48 hours prior to your appointment.
Please note that we are not a part of any Medicaid plans. Please check with your individual plan to make sure we are a participating provider.
List of Body Location and Date of Skin Cancers:
Family History of Skin Problems.
Please List Family Member (father, mother, brother, sister)
I hereby acknowledge that I have reviewed the Notice of Privacy Practices describing the privacy practices and safeguards as well as my rights with respect to my protected health information maintained and used by Aylesworth Dermatology, SC.
I hereby authorize Aylesworth Dermatology, SC to release to the Health Care Financing Administration and its agents (Medicare), Insurance companies or Third parties any information needed to determine benefits payable for related services.
I request that authorized Medicare and/or Insurance payments of medical benefits be made to Aylesworth Dermatology, SC.
I understand that I am ultimately responsible for payment of any and all charges for medical services rendered by Aylesworth Dermatology, SC and if this assignment is rejected, modified, or not paid within a reasonable time after it has been filed, it will be my responsibility to pay any unpaid charges in full. If it is necessary to collect unpaid fees for services rendered, I agree to pay the charge assessed by the collection agency, legal counsel or court.