Calais Dermatology Associates

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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.

______________________________________________________________________________________ _______________________________________

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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.

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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 

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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

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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:

None

less than 1 drink per day

1-2 drinks per day

3 or more drinks per day

Other

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Family Medical History (mother, father, brother, sister or child) indicate with 1

st

letter. Ex. Mother has heart disease _m_

____ Heart Disease

____ Diabetes

____ High Blood Pressure

____ Stroke

____ Cancer

____ Other

Review of Systems: Are you currently experiencing any of the following?

(Please check yes or no for the following)

Symptom

Yes

No

Headaches

Hay fever

Changing moles

Rash

Problems with scarring

Depression

Problems with bleeding

Anxiety

Chest pain

Thyroid problems

Joint aches

Blurry Vision

Bloody Urine

Sore Throat

Shortness of breath

Cough

Muscle weakness

Other Symptoms:

ALERTS: (please check all that apply)

Allergy to Adhesive

Allergy to lidocaine

Allergy to topical antibiotics

Artificial heart valve

Artificial joint replacement

Blood thinners

Defibrillator

MRSA

Pacemaker

Require antibiotics prior to a

surgical procedure

Figure

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References

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