New Patient Form - Minor

PERSONAL INFORMATION

CONTACT INFORMATION

RESPONSIBLE PARTY

INSURANCE INFORMATION

Patient Release: Must be signed by patient if 18 or over, or by legal guardian if patient is under 18

I certify that that 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 examinations and basic treatments for which additional consents are not required. I understand additional written consent may be necessary for certain types of procedures and the legal guardian must be present for such consent.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

History and Intake Form

Past Medical History: (please check all that apply)

Past Surgical History: (please check all that apply)

Skin Disease History: (please check all that apply)

Social History: (Please check all that apply)

Alcohol Use:

Family Medical History: (Mother, Father, Brother, Sister, or Child) indicate with 1st letter.

Ex. Mother has heart Disease M

Calais Dermatology Associates Office Policy

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 provide this documentation, you may pay in full at the time of service and submit the claim to your insurance carrier for reimbursement. I understand by signing below I am responsible for notifying Calais Dermatology Associates of any changes to my insurance.

Payment Policy: Co-Payments, Co-Insurance, Deductibles, and all outstanding balances 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 an 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.

Appointment Cancellations: If I am unable to keep my scheduled appointment, I will call Calais Dermatology to cancel or reschedule my appointment. Surgical appointments require 48-hour cancellation notice. Regular and Cosmetic appointments require 24-hour cancellation notice. Deposits for Cosmetic appointments are nonrefundable in the event the appointment is not cancelled 24 hours in advance.

Skin Biopsies: Calais sends all skin biopsies to Sagis Labs. Sagis provides us with comprehensive diagnostic and prognostic information so we can accurately diagnose the disease, prescribe effective therapies, and initiate early treatment options. If you would like your labs to be sent to a different lab, it is your responsibility to let the nurse know at the time of your visit.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

By signing this form, I understand and agree to abide by Calais Dermatology Associates office policies on this form.

Calais Dermatology Associates 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. 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.

I understand only the individuals listed above will be provided with information. Should I wish to change or delete any of the names listed above, I will contact Calais Dermatology and request a Patient Update form.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Calais Dermatology Associates Notice of Privacy Practices Patient Acknowledgement

I received and understood Calais Dermatology Associate’s Notice of Privacy Practices written in plain language. This notice provides detail on how Medical Information about you may be used and disclosed and how you can get access to this information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices. If changes to the policy occur, this practice will provide me with a revised Notice of Privacy Practices upon request.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.