The Premier Destination for Dermatology and Skin Cancer Care
Virtual and In-Office Appointments: 1-866-599-3376

Patient Information

Welcome to Silver Falls Dermatology & Allergy. We’re pleased that you have chosen us to care for you and your family, and we’d like to make your patient experience as smooth and professional as possible.

 

New Patient Paperwork

If you are instructed to fill out new patient paperwork, please download and print these forms, and bring the completed packet to your first appointment.

Minor Patients

All patients under the age of 18 years of age must be accompanied by a parent or guardian at first visit.

All Patients

Please bring the following information to each appointment:

  • Driver’s license or photo ID
  • Current medical insurance card
  • Insurance co-pay, or Self-Pay co-pay (due at time of service)
  • A list of medications you are currently taking

Missed Appointments and Rescheduling

We understand that circumstances often arise that prevent patients from keeping their appointments. If you are unable to keep an appointment, please call our scheduling department as soon as possible so that we can inform your provider and stay on schedule with other patients.

Notice to Patients

Silver Falls Dermatology & Allergy complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Silver Falls Dermatology & Allergy does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Silver Falls Dermatology & Allergy:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreter
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, contact:

Danielle Sanchez
Phone:971-239-1307 or 866-599-3376
Fax: 503-362-8435
Email: dsanchez@silverfallsderm.net.

If you believe that Silver Falls Dermatology & Allergy has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Danielle Sanchez
1793 13th ST SE Salem, OR 97302
Phone:971-239-1307 or 866-599-3376
Fax: 503-362-8435
Email: dsanchez@silverfallsderm.net

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Danielle Sanchez is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building
Washington,D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Notice of Privacy Practices

Your health information includes information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity and similar types of health-related information.

We are required by law to notify you about the ways in which we may use and disclose health information about you, and to describe your rights and our obligations regarding the use and disclosure of that information. Read the full notice here.

Confidential Hotline

Employees, providers, patients and teammates can report compliance concerns safely and anonymously.

  • Workplace issues
  • HIPAA and security
  • Coding compliance
  • Stark laws or anti-kickback violations
  • Any other sensitive subjects

Safe Hotline is an independent third-party service that can be used to report concerns for any of our locations. All reports received will be submitted exactly as they are received, and your identity will not be disclosed without your permission.

The hotline is easily accessed by phone, text or online. Our company code is required with every report, so that concerns can be properly directed.

Call or Text
1-855-662-SAFE
(1-855-662-7233)

Online
SAFEHOTLINE.COM

Company Code (required)
0777756263

Once a report is made, the person is given a onetime key code that can be used to check the status of the report.

The compliance hotline is not an emergency number and should not be used in place of 9-1-1.

Telephone Relay Service

Oregon Telecommunications Relay Service is a free public service for communication between standard (voice) users and persons who are deaf, hard-of-hearing, deaf-blind, and speech-disabled using text telephones (TTYs) or PCs via the Internet.

  • Voice
  • TTY
  • ASCII
  • TeleBraille
  • Spanish
  • Voice Carry-Over
  • Speech-to-Speech
  • Hearing Carry-Over
  • 900 Toll Service
  • International Calling
  • TTY Public Payphones
  • Directory Assistance
  • Answering Machine
  • Emergency Call

If you have difficulty using the telephone, please use this HIPAA-Compliant service to communicate with our office or make appointments.

Oregon le ofrece el servicio de relevo a nuestros clientes en español. Los consumidores de TTY pueden escribir por máquina en español y las conversaciones serán retransmitidas en español y ingles.

http://www.oregonrelay.com/