Patient Intake Form

Name

Date:

First Name:

Middle Name:

Last Name:

Address

Street Address:

Street Address Line 2:

City:

State/Province:

Zip Code:

Email

Email Address:

Drivers License/Government ID:

Drivers License Number/Government ID:

State

Sex: What is your current gender identity? Check ALL that apply:

Gender Identity:

Male

Gender Queer/Nonbinary

Transgender Female/Transwoman/MTF

Female

Transgender Male/Transman/FTM

Additional Category (please specify):

What sex were you assigned at birth?

Marital Status:

Birthdate:

Age:

Patient Employer/School:

Employer/School Address:

Employer/School Phone Number:

Spouse's Name

First Name:

Last Name:

Birthdate:

Whom may we thank for referring you?

Phone Numbers

Home Phone:

Cell Phone:

Best time and place to reach you:

In Case of Emergency, Contact

First Name:

Last Name:

Relationship:

Phone Number:

Work Phone Number:

Privacy Information

Any contact information listed on this form, including phone numbers and email, will be used by this office to contact you about future appointments, billing, and routine correspondence.

Consent for Others to Access Your Account & Records:

I give my consent for (i.e. spouse, partner, adult child, etc.) to discuss and/or obtain my NOPA-related account information in person, by phone, or by email. I understand I may revoke given consent in writing at any time.

Parent/Guardian Signature:

Date

PODIATRIC HISTORY

What is the chief complaint for which you came to be treated?:

Have you ever utilized a podiatrist or orthopedic for foot related issues?

Yes No

Is there any personal or family history of diabetes?

Yes No

Your Occupation:

Have you ever used tobacco?

Yes No

Which types and for how long?

When did you quit/are you currently using tobacco?

Do you consume alcohol?

Yes No

Which types?

How often?

Have you ever had a drug or alcohol addiction?

Yes No

Please explain your addiction:

For how long/are you currently in recovery?

Medical History

Surgeries you have had:

Hospitalizations (excluding above surgeries)

Family Physician:

Last Visit Date:

Are you now or have you been under any other doctor's care for any reason over the past two years?

Yes No

If yes, Please explain:

MEDICATIONS

In the event Dr. Lang recommends a prescription, your online prescription history will be accessed and reviewed.

Include prescriptions, over-the-counter medications, and vitamins:

Pharmacy Name:

Pharmacy Phone Number:

Treatment Consent

I hereby consent and give my permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such procedures upon me or my minor child as the doctor deems necessary.

Signature of Patient, Parent, Guardian, or Personal Representative

Date

Printed name of Patient, Parent, Guardian, or Personal Representative

Relationship to Patient:

Consent for Purposes of Treatment, Payment, Healthcare Operations, and HIPAA

You have the right and choice to tell New Orleans Podiatry Associates hereafter referred to as “NOPA” to share information with your family, close friends, or others involved in payment for your case and/or to share information in a disaster relief situation.

We will never share your information with unaffiliated entities for marketing purposes or sales unless you give us written permission.
You may request that we contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will consider all reasonable requests and must comply if you tell us you would be in danger if we do not.
You may request to see or obtain a copy of your health and claims records and other patient information. We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable fee. You have a right to gain access to our online portal for all health and claims records, at no charge. Please ask us how if you are interested.
You may request that we not use or share certain health information for treatment, payment, or our operations. However, we are not required to comply with this request and may deny it if it would affect your care.
You may request a report detailing the times we have shared your health information, up to six years prior to the desired date, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations. We'll provide one report for free within a 12-month period. For any additional accounting within a 12-month period, there will be a reasonable fee.
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has authority and can act for you before we take any action.
You may complain if you feel we have violated your rights by contacting us, or you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting:
www.hhs.gov/ocr/privacy/hipaa/complaints/ We will not retaliate against you for filing a complaint.
You can ask us to correct your health and claims records if you think they are incorrect or incomplete. If we deny your request, we will send you a written explanation within 60 days.
We must follow the duties and privacy practices described in this notice. You may request for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
We are required by law to maintain the privacy and security of your protected health information. We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information. We will not use or share your information other than as described below unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. For more information visit:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

NOPA can share your health information in the following circumstances:

with organ procurement organizations
with a coroner, medical examiner, or funeral director when an individual dies
for workers' compensation claims
for law enforcement purposes or with a law enforcement official
for special government functions such as military, national security, and presidential protective services
in response to a court or administrative order, or in response to a subpoena
for public health reasons:
- preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; preventing or reducing a serious threat to anyone's health or safety
for health research
if state or federals laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law
with other medical professionals who are treating you
with our recovery agency to collect any outstanding debt
We can discuss your diagnosis and treatment plan for purposes of obtaining insurance information or reimbursement

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our website, and we will mail a copy to you.

Consent

I hereby give my consent for the physicians and team of New Orleans Podiatry Associates to use and disclose protected health information about me to carry out treatment, bill insurance carriers, and to conduct normal healthcare operations.

I acknowledge by my signature that I have read both pages of this Consent for Purposes of Treatment, Payment, Healthcare Operations, and HIPAA, and I have been given a copy for my personal use.

Patient First Name:

Patient Last Name:

Signature of Patient, Parent, Legal Guardian, or Agent (attorney-in-fact):

Date

Name of Representative:

Relationship to Patient:

Patient Responsibility

New Orleans Podiatry Associates and its representatives are not authorized to quote medical benefits to you; however, we will share with you the information your insurance carrier has provided us. Many of our patients rely on this data to make treatment decisions, however, this information is sometimes inaccurate. Therefore, it is your responsibility to contact your insurance carrier before receiving treatment to ensure we are a provider for your insurance plan, and/or to learn how your visits with our doctors will be reimbursed.

Upon request, this office will provide you with the diagnosis codes and procedure codes related to your treatment. These codes are needed by your carrier to obtain coverage information.
According to industry standards, New Orleans Podiatry Associates will file your medical claims for all applicable medical services and appliances rendered to you by our physicians, unless an ABN or similar waiver is signed.

Co-payments, co-insurances, non-covered services and deductible responsibilities are due at time of service.

In order to bill your insurance carrier, New Orleans Podiatry Associates shall maintain a copy of your insurance card(s) as per our contract with your insurance carrier. At least 24 hours prior to your visit it is your responsibility to ensure our office has your most current insurance information or your appointment may be rescheduled.

In order to bill your insurance carrier, New Orleans Podiatry Associates shall maintain a copy of your driver's license or State ID as per our contract with your insurance carrier. At the time of your initial visit, it is your responsibility to ensure you bring with you the above identification or your appointment may be rescheduled.

In order to bill your insurance carrier, if you are an established patient and you have made a change to your insurance coverage and you do not have your new insurance card or a copy of the card with you at the time of your visit, you will either be rescheduled or you may choose to pay out of pocket for your visit and services when rendered.

In all cases, if your insurance carrier places expenses to your financial responsibility, then you, the patient, are responsible for those charges, due on the date of service or upon receipt of invoice. Non-collectible debt will be shared with a recovery agency.

The accounts of minor children are the responsibilities of their parents or legal guardians. In the event there is a non-collectible debt associated with the account for a minor child, the parent or legal guardian will be held responsible and their information will be shared with a recovery agency.

Our banking institution charges for returned checks; therefore, and without exception, a $50.00 service charge will be billed to you in the event your check is returned for any reason.

If you choose to use a debit or credit card to pay for services, a 3% service charge will be added to your total and placed to your responsibility. This fee is one-half of what we are charged to process your card; we are splitting the difference with you.

If you are a caregiver and you accompany a cognitively compromised individual to our office for medical care, a medical power of attorney is necessary before the individual will be accepted into our practice as a patient.

We will file all charges with Medicare and your supplemental insurance if applicable. If you do not have supplemental insurance, you are responsible for the 20% not paid by Medicare, or any deductible that has not been met at the time of service.

Regarding workmen’s compensation/auto/liability, our office requires a very specific authorization prior to the initial visit. If the authorization has not been received by the time of your visit, then your personal health insurance information will be taken for filing purposes or you may pay out of pocket at the time services are rendered. You will be responsible for all fees until the case has been settled. We do not bill attorneys in workmen’s compensation, auto and/or liability cases.

Patients under the age of 18 must have a parent and/or guardian accompany them to our office before treatment can be rendered. Arrangements must be made prior to being seen with the parent and/or guardian for any copays and payments to be made at the time of treatment.

Our office uses both an out of state laboratory as well as an in-house, physician owned laboratory for PCR services, bacterial cultures and fungal cultures. In the event that a lab test is performed, you will receive a separate bill for the lab services.

If your insurance does not cover orthotics or your deductible has not been met, a deposit of half the price of the orthotics will be expected prior to ordering. The remaining half is due at the time your orthotics are dispensed.

I understand that if I fail to satisfy my financial responsibility with New Orleans Podiatry Associates, I imply discontinuation of podiatry services with this clinic.

I have read, understand, and agree to the above. By signing below, I attest that my questions have been answered and I agree to comply with the patient responsibilities policies.

Patient First Name:

Last Name:

Signature of Patient, Parent, Legal Guardian, or Agent (attorney-in-fact):

Date

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