New Patient Form - Minor

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)

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

Ex. Mother has heart Disease M

Calais Dermatology Associates Office Policy

1. Insurance Card(s): I understand that I am required to provide a valid insurance card at check-in for my visit. It is my responsibility to notify Calais Dermatology of any updates or changes to my insurance. If I am unable to provide a valid insurance card, I understand that I will need to reschedule my appointment until I can provide the necessary documentation.
2. Payment Policy: I acknowledge that all co-payments and outstanding balances, that may include co-insurance and deductibles, are required to be collected at check in. I understand all cosmetic treatments must be paid for at the time of service.
3. Account Balance: I am responsible for the timely payment of my account balance. If my balance remains unpaid after three statements have been sent, further action may be taken to resolve the balance.
4. Limited Benefit Plans: Our office does not contract with Limited Benefit Plans (LBPs). These plans provide coverage for specific services or conditions with predetermined monetary caps. If you have an LBP, you will be treated as a self-pay patient. We will provide the necessary information for you to submit to your LBP for potential reimbursement.
5. Skin Biopsies: I understand that skin biopsies are sent to Sagis, SkinDX, or Borsting laboratories for analysis. These labs have been selected based on their ability to provide comprehensive diagnostic and prognostic information, which is essential for accurate disease diagnosis, prescribing effective therapies, and determining initial early treatment options. I understand it is my responsibility to inform Calais Dermatology if I prefer my skin biopsy to a different lab due to my insurance coverage.
6. Appointment Cancellation and No-Show Policy: We value your time and strive to provide the best care possible. To offer appointments to all our patients, we ask for your cooperation with the following cancellation and no-show policy.
   1. We require 24 hours advance notice for the cancellation or rescheduling of any appointment. This allows us to accommodate other patients who may need care.
   2. If you do not show up for your scheduled appointment without providing the required 24-hour notice, you will be charged a $50 no-show fee for all medical appointments, and a $100 no show fee for all cosmetic appointments.
7. Return Policy: At Calais Dermatology, we strive to provide the highest quality care and products for our patients. To ensure the safety and integrity of all products, please note that all medications and products purchased at Calais Dermatology are nonreturnable.
8. NSF Checks: I understand that if I issue a check that is returned for insufficient funds, I will be charged a $75 NSF fee. I will make alternative payment arrangements if necessary.
9. Minor Patients: A legal guardian must accompany children under the age of 18 to all appointments.

I have read and fully understand Calais Dermatology’s office policy and acknowledge my responsibilities as outlined within.

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.