Calais Dermatology Associates
Please present ALL insurance cards to the receptionist. If patient is a minor, and you are not the legal guardian, please ask receptionist for minor paperwork. Patient Information: Please Complete All Fields
Using Legal Names of the Parties Involved.
Name: (First)__________________________ (MI)______(Last)______________________________________________________ D.O.B:____________________ Age:______ Sex: □ M □ F Status: □Single □Married □Divorced □Widowed Mailing Address:___________________________________________________________ Race:_____________________________ City:_______________________________ State:_________ Zip:_______________ Social #:________________________________ Cell:_______________________ Home:______________________ Email:________________________________________________ Employer:________________________________________________________________ Work #:____________________________ Referring Dr:____________________________________________________________ Town:_______________________________ Pharmacy:_____________________________________________ Street/Town:________________________________________ How did you hear about Calais Dermatology?_______________________________________________________________ Our current computer system sends appt. reminders by text or email. Would you prefer?
□ Text □ Email □ Neither
Due to increasing costs of stamps and our computer system, we can now send billing statements to your email. Please specify your preference. □ Email □ Mail
Insurance Info:
Primary Ins.:____________________________________ Grp #_________________ ID#_________________________________ Policy Holder:_______________________________________________________________ D.O.B:___________________________
Patient Release: Must be signed by patient if 18 or over, or by legal guardian if patient is under 18
I certify that the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare) for the purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider.
I certify that I hereby authorize Calais Dermatology, its providers and staff to provide my minor child in my absence with examination and basic treatments for which additional consents are not required. I understand as the legal guardian of this child I am required to be physically present to consult with the provider on many procedures which require separate consent. I understand additional written consent may be necessary for certain types of procedures and that the legal guardian must be present for such consent.
______________________________________________________________________________________ _______________________________________
Patient Name: ________________________________________________________________ Patient/Guardian Signature
:________________________________
Date:____________
By signing this form I understand and agree to abide by Calais Dermatology’s office policies stated on this form. Insurance Card Policy:We require you to confirm that your insurance is current at each office visit. New patients or existing patients with a change in their insurance information must provide a valid insurance card or temporary print out at the time of the visit. Should you be unable to produce this documentation, you may pay in full at the time of service and submit the claim to your insurance carrier for reimbursement. I understand that by signing below I am responsible for notifying Calais Dermatology of any changes to my insurance.
Insurance Referral Policy:
If my insurance plan requires a referral, I understand that it is my responsibility to obtain an updated referral from my Primary Care Provider and to make sure that Calais Dermatology has the referral before my visit. I understand that it is my responsibility to keep track of the number of visits I have used on my referral and the expiration date of my referral and to obtain new ones as needed.
Co-Payment Policy:
Co-payments are due and collected on the day of my or my family’s appointment. Account Balances:
I am responsible for the timely payment of my account balances, co-insurance and deductibles. All balances are due in full within 30 days of my first billing. Any balance left unpaid after 90 days, without any attempt at resolution, will be considered delinquent and may be submitted to a collection agency. If I am having financial difficulty, I will call the billing office to discuss a payment plan.
Minor Patients:
A legal guardian must accompany children under the age of 18 to their initial appointment so that the proper forms can be filled out and signed. Follow up visits do not require a guardian’s presence, unless a procedure is being performed that requires a signed consent form.
College Students:
If you are a college student on your parent’s insurance plan, your insurance company will require a form to be completes confirming your student status. These forms are mailed to your home address and must be completed and returned within 30 days. If these forms are not returned within the time frame, you will be financially responsible for all charges incurred.
Insurance Requests:
Your insurance company will periodically require a form to be completed concerning coordination of benefits or whether you have other insurance coverage. These forms are mailed to your home address and must be
completed and returned within 30 days. If these forms are not returned within the time frame, you will be financially responsible for all charges incurred.
Appointment Cancellations:
If I am unable to keep my scheduled appointment, I will call Calais Dermatology to cancel or re-schedule my appointment. Regular appointments require 24-hour cancellation notice. Cosmetic and Surgical appts require 48-hour cancellation notice.
Calais Dermatology Associates HIPPA Policy
Patient Name: ____________________________________ HIPAA Policy:
Patients over the age of 18 are protected under the Federal Health Insurance Portability and Accountability Act. This Federal Law prohibits any staff member of Calais Dermatology from discussing appointments, medication, test results or treatment plans with anyone other than the patient. Often, this causes difficulty for some patients who would like family members or caretakers to obtain information for them. This becomes especially important if your spouse assists with making appointments for you or if you are an adult college student away at school and your parents assist with prescriptions and appointments. If you would like to permit someone to discuss your medical condition, confirm appointments or obtain results for you, please indicate their name(s) below. Only these individuals will be provided with information. Should you wish to update the names provided below, please ask the receptionist for a HIPAA Form.
Name of Individual (please print) Relationship to Patient
1.____________________________________________________________________________________ 2.____________________________________________________________________________________
Please check off which of the following methods we may use to contact you regarding your appointments and medical and billing information.
Leave a Message Regarding Appts. Med. /Billing Info Home Answering Machine? ____ Office Voicemail? ____ ____
With Another Person? ____ ____ Sent through mail? ____ ___
Sent via e-mail? ____ _
Cell phone? ____ ____
Patient/Guardian Signature:___________________________________ Date:___________
I acknowledge and understand the above HIPAA policies and have received a copy of the practice’s
Notice of Privacy Practices related to the Health Insurance Portability and Accountability Act of 1996 and HITECH policy.
Calais Dermatology Associates, 5220 Flanders Drive, Baton Rouge, LA 70808 225‐766‐5151
History and Intake Form
Reason For Visit:_____________________________________________________________________
Patient’s Name:_______________________________________________________________________
Past Medical History: (please check all that apply)
Anxiety
Arthritis
Asthma
Atrial fibrillation
Bone Marrow
Transplantation
Breast Cancer
Colon Cancer
COPD
Coronary Artery
Disease
Depression
Diabetes
End Stage Renal
Disease
GERD
Hearing Loss
Hepatitis
High Blood pressure
HIV/AIDS
High Cholesterol
Thyroid Problems
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke
NONE
Other _________________________________________________________________________________________
Past Surgical History: (please check all that apply)
Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Joint Replacement, Knee (Right, Left,
Bilateral)
Joint Replacement, Hip (Right, Left,
Bilateral)
Joint Replacement within last 2 years
Kidney Biopsy (Nephrectomy)
Kidney Removed (Right, Left)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
TURP (Prostate Removal)
Spleen Removed
Testicles Removed (Right, Left,
Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
NONE
Skin Disease History: (please check all that apply)
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever/Allergies
Melanoma
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin
Cancer
NONE
Other
Do you wear Sunscreen?
Yes
No
If yes, what SPF?
Do you tan in a tanning salon?
Yes
No
Do you have a family history of Melanoma?
Yes
No
If yes, which relative(s)?
Medications: (Please enter all current medications)
Drug Allergies: (Please enter all allergies)
Social History: (Please check all that apply)
Cigarette Smoking:
Currently Smokes
Has smoked in the past
Never smoked
Former Smoker
Alcohol Use:
