Insurance and Forms


 

Patient Forms


Records Release

Patient medical release of records form.

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Registration

Patient registration, insurance, and records release form.

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Notice of Privacy

The Notice of Privacy Practices form describes how patient medical information is used and disclosed and how you, the patient, can have access to this information.

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Patient Authorization

The General Patient Authorization form describes our practice policies and payment policies and procedures. It also outlines policies regarding release of patient information.

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Minor Consent

The Minor Consent to Treat form allows the providers in our office to see and treat your child when a parent in not present. All surgical procedures do, however, do require a parent being present.

 Download Here


Medical Insurance

We accept the following providers:

  • AARP Secure Horizon Complete
  • Aetna Commercial
  • Aetna Medicare PPO & HMO
  • BCBS TX Essentials HMO
  • BCBS TX Medicare PPO
  • BCBS TX PPO/POS
  • BCBS TX Premier HMO
  • Blue Advantage HMO Exchange
  • Care N’ Care
  • Cigna
  • Coventry
  • First Health
  • Galaxy Health Network
  • HealthSmart Accel
  • HealthSmart GEPO
  • HealthSmart PPO
  • Humana Advantage Plus
  • Humana Choice Care
  • Humana Medicare HMO
  • Humana Medicare PPO/PFFS
  • IMS PPO
  • SmartCare/Imagine Health PPO
  • UHC Medicare Adv
  • United Healthcare
Location
Betty Rajan, MD: Dermatology & Skin Care
6600 Bryant Irvin Road
Fort Worth, TX 76132
Phone: 817-612-9796
Fax: 817-820-0073
Office Hours

Get in touch

817-612-9796