Cosmetic Procedure Form

Removal of the following benign lesion(s) is not medically necessary and therefore cosmetic in nature. Removal of these lesions is not covered by the insurance companies.

Payment for any procedure is expected at the time of each visit.

• Skin tags
• Small cysts, not inflamed
• Benign appearing moles
• Benign keratoses (i.e. seborrheic keratoses)
• Benign age spots
• Angiomas (i.e. cherry angiomas)
• All lesions deemed benign and cosmetic by the provider
• All laser treatments
• Leg vein therapy
• Cosmetic skin care products dispensed by our aesthetic specialists
• Cosmetics consults

Payment for any cosmetic procedure(s) is expected at the time of each visit.

Please do not ask the physician to code benign procedures through your insurance as that is considered to be insurance fraud.

Ask the physician for a cosmetic quote if you would like to have a benign lesion removed.