Calais Dermatologyassociates (Minor)

Calais DermatologyAssociates (Minor)

PleasepresentALL insurancecardsto thereceptionist.Wedonotbill absent parents,theadult presentingtheminorforcareis theresponsible party.PatientInformation:PleaseComplete AllFieldsUsingLegalNamesof thePartiesInvolved.

Minor patientinformation:

Name:(First) (MI)(Last)_

D.O.B:Age:Sex:□M □F Social#Race:_

MailingAddress:_

StreetaddressorP.O.CityZip code

Mother’s Cell:Father’sCell: Home:__

Emergency Name and #______Relationship to patient:______

ResponsibleParty:

Name: Relationship:

SS#D.O.B.:Email:

Address:

ReferringDr:Town:__

Pharmacy:Street/Town:__

Ourcurrentcomputersystemsendsappt. remindersbytextoremail. Wouldyou prefer?

□Text□Email□Neither

Due to increasingcostsof stampsandour computersystem, wecan nowsendbillingstatementsto youremail. Please specifyyourpreference. □Email □ Mail

InsuranceInfo:

PrimaryIns.: Grp# ID#

PolicyHolder: D.O.B:

PatientRelease:Must besigned by patientif 18 or over,orbylegal guardian if patientisunder18

Icertifythat the informationthat Ihaveprovidediscorrect.Iauthorize the releaseof medicalinformation necessaryto processinsuranceclaimstoinsurancecompaniesortheiragencies(includingMedicare)for the purposeoffilingand paymentof medicalclaims.I authorizepaymentof medicalbenefitstothe provider.

Icertifythat IherebyauthorizeCalaisDermatology,itsprovidersandstaff toprovidemy minorchildinmyabsencewith examinationsandbasic treatmentsforwhichadditionalconsentsare notrequired.Iunderstandadditionalwritten consentmaybenecessaryfor certain typesofproceduresand the legalguardian mustbepresentforsuchconsent.

______

______

Patient/GuardianSignatureDate

PatientName:

Patient/GuardianSignature:Date:

By signing thisformI understand and agree toabidebyCalais Dermatology’s officepoliciesstated on this form.

InsuranceCardPolicy:

Werequireyoutoconfirmthatyourinsuranceiscurrentateachofficevisit.Newpatientsorexistingpatients withachangeintheirinsuranceinformationmustprovideavalidinsurancecardortemporaryprintoutatthe timeofthevisit.Shouldyoubeunabletoproducethisdocumentation,youmaypayinfullatthetimeofservice andsubmittheclaimtoyourinsurancecarrierforreimbursement.IunderstandthatbysigningbelowIam

responsiblefornotifyingCalaisDermatologyofanychangestomyinsurance.

InsuranceReferralPolicy:

If myinsuranceplanrequiresareferral,Iunderstandthatitismyresponsibilitytoobtainanupdatedreferral frommyPrimaryCareProviderandtomakesurethatCalaisDermatologyhasthereferralbeforemyvisit.I understandthatitismyresponsibilitytokeeptrackofthenumberofvisitsIhaveusedon my referralandthe expirationdateof myreferralandtoobtainnewonesasneeded.

Co-PaymentPolicy:

Co-paymentsaredueandcollectedonthedayofmy ormyfamily’sappointment.

AccountBalances:

Iamresponsibleforthetimelypaymentofmyaccountbalances,co-insuranceanddeductibles.All balancesaredueinfullwithin30daysofmyfirstbilling.Anybalanceleftunpaidafter90days,withoutany attemptatresolution,willbeconsidereddelinquentandmaybesubmittedtoacollectionagency.IfIamhaving financialdifficulty,Iwillcallthebillingofficetodiscussapaymentplan.

MinorPatients:

Alegalguardianmustaccompanychildrenundertheageof18totheirinitialappointmentsothattheproper formscanbefilledoutandsigned.Followupvisitsdonotrequireaguardian’spresence,unlessaprocedureis beingperformedthatrequiresasignedconsentform.

CollegeStudents:

Ifyouareacollegestudentonyourparent’sinsuranceplan,yourinsurancecompanywillrequireaformtobe completesconfirmingyourstudentstatus.Theseformsaremailedtoyourhomeaddressandmustbecompleted andreturnedwithin30days.Iftheseformsarenotreturnedwithinthetimeframe,youwillbefinancially responsibleforallchargesincurred.

InsuranceRequests:

Yourinsurancecompanywillperiodicallyrequireaformtobecompletedconcerningcoordinationofbenefitsor whetheryouhaveotherinsurancecoverage.Theseformsare mailedtoyourhomeaddressandmustbecompletedandreturnedwithin30days.Iftheseformsarenotreturnedwithinthetimeframe,youwillbefinanciallyresponsibleforallchargesincurred.

AppointmentCancellations:

IfIamunabletokeepmyscheduledappointment,IwillcallCalaisDermatologytocancelorre-schedulemy appointment.Regularappointmentsrequire24-hourcancellationnotice.CosmeticandSurgicalappts require48-hourcancellationnotice.

CalaisDermatologyAssociatesHIPAAPolicy

PatientName:

HIPAAPolicy:

Patientsovertheageof18areprotectedundertheFederalHealthInsurancePortabilityandAccountability Act.ThisFederalLawprohibitsanystaffmemberofCalaisDermatologyfromdiscussingappointments, medication,testresultsortreatmentplanswithanyoneotherthanthepatient.Often,thiscausesdifficulty for somepatientswhowouldlikefamilymembersorcaretakerstoobtaininformationforthem.This becomesespeciallyimportantifyourspouseassistswithmakingappointmentsforyouorifyouareanadult collegestudentawayatschoolandyourparentsassistwithprescriptionsandappointments.

Ifyouwouldliketopermitsomeonetodiscussyourmedicalcondition,confirmappointmentsorobtain resultsforyou,pleaseindicatetheirname(s)below.Onlytheseindividualswillbeprovidedwith information.Shouldyouwishtoupdatethenamesprovidedbelow,pleaseaskthereceptionistfora HIPAAForm.

NameofIndividual(pleaseprint)RelationshiptoPatient

1.

2.

Pleasecheckoffwhichofthefollowingmethodswemayusetocontactyouregardingyour appointmentsandmedicalandbillinginformation.

LeaveaMessageRegardingAppts.Med./BillingInfo

HomeAnsweringMachine? OfficeVoicemail?

WithAnotherPerson? Sentthroughmail?

Sentviae-mail?_

Cellphone?

Patient/Guardian Signature:

Date:

IacknowledgeandunderstandtheaboveHIPAApoliciesandhavereceivedacopyofthepractice’s

NoticeofPrivacyPracticesrelatedtotheHealthInsurancePortabilityandAccountabilityActof1996andHITECH

policy.

CalaisDermatologyAssociates,5220FlandersDrive,BatonRouge,LA70808225‐766‐5151

Historyand IntakeForm

ReasonFor Visit:______Patient’sName:______

Past MedicalHistory:(pleasecheckall that apply)

Anxiety

Arthritis

Asthma

Atrialfibrillation

BoneMarrow

Transplantation

BreastCancer

ColonCancer

COPD

CoronaryArtery

Disease

Depression

Diabetes

EndStage Renal

Disease

GERD

HearingLoss

Hepatitis

HighBloodpressure

HIV/AIDS

HighCholesterol

ThyroidProblems

Leukemia

LungCancer

Lymphoma

ProstateCancer

RadiationTreatment

Seizures

Stroke

NONE

Other

Past SurgicalHistory:(pleasecheckall that apply)

Adenoids/ Tonsillectomy

Appendix (Appendectomy)

Bladder (Cystectomy)

Breast Biopsy

 Breast: Lumpectomy (B, L, R)

 Breast: Mastectomy (B, L, R)

 Colon (Colectomy): Colon Cancer/Diverticulitis/Inflammatory Bowel Disease

Gallbladder: (Cholecystectomy)

Heart: Coronary Artery Bypass Surgery

Heart: Biological/ Mechanical Valve Replacement

 Heart: PTCA

 Joint Replacement Hip/Knee: (B, L, R)

 Kidney Biopsy (Nephrectomy)

Kidney Removed

Kidney Stone Removal



Kidney Transplant

 Liver: Hepatectomy

 Liver Transplant

 Liver: Shunt

 Ovarian Cyst

 Ovaries: Endometriosis/ Tubal Ligation

 Pancreas: Pancreatectomy

 Prostate Biopsy or Cancer

 Prostatectomy: TURP

 Rectum: Low Anterior Resection/APR

 Skin: Biopsy/ Melanoma / Basal Cell Carcinoma/ Squamous Cell Carcinoma

 Spleen (Splenectomy)

 Testicles (Orchiectomy)

 Uterus (Hysterectomy): Fibroids/ Uterine Cancer/Cervical Cancer

NONE

Other

SkinDiseaseHistory:(pleasecheckall that apply)

Acne

ActinicKeratoses

Asthma

BasalCellSkinCancer

BlisteringSunburns

DrySkin

Eczema

FlakingorItchyScalp

HayFever/Allergies

Melanoma

PoisonIvy

PrecancerousMoles

Psoriasis

SquamousCellSkin

Cancer

NONE

Other

DoyouwearSunscreen?YesNo

Ifyes,what SPF?

Doyoutan ina tanningsalon?YesNo

Doyouhavea familyhistoryofMelanoma?YesNo

*excludingBasalandSquamousCell Carcinomas*

Ifyes,whichrelative(s)? HaveyoureceivedyourFluShotthisyear? YesNo

Haveyoureceiveda Pneumoniashotinthe past?YesNo

Medications:(Pleaseenterall currentmedications)withdosage and frequency

DrugAllergies:(Pleaseenterall allergies)

Social History:(Pleasecheckall that apply)

Cigarette Smoking:

CurrentlySmokes

FormerSmoker

Neversmoked

AlcoholUse:

None

Lessthan 1drinkperday

1-2drinksperday

3ormoredrinksperday

FamilyMedicalHistory(mother,father,brother,sisterorchild)indicatewith1st

letter.Ex.Motherhasheartdisease_m_

HeartDisease

HighBloodPressure

Cancer

Diabetes

Stroke

Other

Are youcurrentlyexperiencinganyofthe following?(Pleasecheckyesorno forthe following)

Symptom:YESNO

HairLoss
Rash
Problems with scarring
Problems with bleeding

OtherSymptoms:

ALERTS:(pleasecheckall that apply)

AllergytoAdhesive

Allergyto lidocaine

Allergyto topicalantibiotics

Artificialheartvalve

Artificialjoint replacement

Bloodthinners

Defibrillator

MRSA

Pacemaker

Requireantibioticspriorto a surgicalprocedure

Rapidheartbeatwithepinephrine

Areyoupregnantorcurrently tryingto get pregnant?