Calais Dermatology Associates

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1 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: 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 . Would you prefer? Text Neither Due to increasing costs of stamps and our computer system, we can now send billing statements to your . Please specify your preference. 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/Guardian Signature Date

2 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. 2

3 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 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 Voic ? With Another Person? Sent through mail? Sent via ? 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

4 History and Intake Form Reason For Visit: Patient s Name: Past Medical History: (please check all that apply) Anxiety Disease Arthritis Depression Asthma Diabetes Atrial fibrillation End Stage Renal Bone Marrow Disease Transplantation GERD Breast Cancer Hearing Loss Colon Cancer Hepatitis COPD High Blood pressure Coronary Artery 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 Joint Replacement within last 2 years Bladder Removed Kidney Biopsy (Nephrectomy) Mastectomy (Right, Left, Bilateral) Kidney Removed (Right, Left) Lumpectomy (Right, Left, Bilateral) Kidney Stone Removal Breast Biopsy (Right, Left, Bilateral) Kidney Transplant Breast Reduction Ovaries Removed: Endometriosis Breast Implants Ovaries Removed: Cyst Colectomy: Colon Cancer Resection Ovaries Removed: Ovarian Cancer Colectomy: Diverticulitis Prostate Removed: Prostate Cancer Colectomy: IBD Prostate Biopsy Gallbladder Removed TURP (Prostate Removal) Coronary Artery Bypass Spleen Removed Mechanical Valve Replacement Testicles Removed (Right, Left, Biological Valve Replacement Bilateral) Heart Transplant Hysterectomy: Fibroids Joint Replacement, Knee (Right, Left, Hysterectomy: Uterine Cancer Bilateral) NONE Joint Replacement, Hip (Right, Left, Bilateral) Other

5 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

6 Family Medical History (mother, father, brother, sister or child) indicate with 1 st letter. Ex. Mother has heart disease _m Heart Disease High Blood Pressure Cancer Diabetes Stroke 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 Rapid heartbeat with epinephrine Are you pregnant or currently trying to get pregnant?

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