New Patient Form

WELCOME

PRIVACY INFORMATION

Consent for Others to Access Your Account & Records

I give my consent for (Please input Name below) to discuss and/or obtain my NOPA- related medical and account information in person, by phone, or by mail. I understand I may revoke given consent by certified mail or by completing a form in person.

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

Patient/Guardian signature:

Date

PATIENT INFORMATION

Date

Last Name

First Name

Middle Initial

Address

City

State

Zip

E-mail

What sex were assigned at birth? (Important information to accurately compile your treatment protocol)

Male Female

Current gender identity:

Age

Birthdate

Patient Employer/School

Whom may we thank for referring you?

PHONE NUMBERS

Home Phone

Cell Phone

IN CASE OF EMERGENCY, CONTACT

Name

Relationship

Home Phone

Work Phone

PODIATRIC HISTORY

What is the chief complaint for today’s visit?

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

Yes No

If yes, please let us know for which conditions you sought treatment:

Date:

Which Treatment modalities were utilized?

Did the treatment work?

Yes No

Explain:

Is there any personal or family history of diabetes?

Yes No

Cigarette/Tobacco use:

Years you smoked:

Do you consume Alcohol?

Yes No

If so, which types?

How Often?

MEDICAL HISTORY

Please indicate if you have had any of the following:

Surgeries You Have Had

Hospitalizations (excluding above surgeries)

Family Physician

Last Visit Date

Are you now or have you ever 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(s)

Pharmacy Phone(s)

ALLERGIES

Other

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

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

Signature of Patient, Parent, Guardian, or Personal Representative

Date

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

Relationship to Patient

PRIVACY INFORMATION

Any phone number (not including your emergency contact) listed on this form, will be used by this office to contact you about appointments, medical information, billing, and general correspondence. We will not leave medical information on voicemail however, we will utilize voicemail to remind you of appointments, billing concerns, or to request for a return call. Emails generated from our office will include information about appointments, in-office promotions, and billing. In addition, we utilize “Doctible” a patient texting platform. Utilizing this platform, we will text you your appointment information. As a patient, you may use our patient communication platform to text Dr. Lang questions about your healthcare, including private-protected healthcare information from 7AM to 9PM daily. He will respond by text on that platform.

Voicemail

We will not leave medical information on voicemail however, we will utilize voicemail to remind you of appointments, billing concerns, or to request for a return call. I understand that any phone number listed on this Intake Form will be utilized for appointments, billing concerns, or call requests.

I give my consent for Dr. Lang, his representatives, and the representatives of New Orleans Podiatry Associates to leave voicemails on any on the phone numbers I have indicated on this Intake Form.

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

Signature of Patient, Parent, Guardian, or Personal Representative

Date

E-Mail

We utilize Microsoft Office 365, a HIPAA compliant e-mail provider. Although Office 365 is a HIPAA compliant e-mail service, unless you are utilizing an Office 365 account, we cannot guarantee that medical information shared through e-mail will be protected. If you are requesting any medical records or medical information by email, you will be required to sign a waiver stating that you understand the risks of e-mailing protected medical information and only then will medical information be e-mailed to you. That form is located on our website under medical forms. It can be completed online and sent to us electronically. Otherwise, e-mails generated from our office will include information about appointments, in office promotions, and billing. If you require protected medical information to be sent to you by e-mail, you will receive a one-time use passcode, provided by our office, to access the encrypted e-mail containing your requested medical information.

I give my consent for Dr. Edward Lang and New Orleans Podiatry Associates to utilize my e-mail for the purpose of corresponding with me for appointments, promotions, and billing. I understand that if I want protected medical information to be e-mailed and I do not have an Office 365 account, I will be required to fill out a request. I understand that any medical information that I request will be potentially at risk of a third-party, unless I request a one-time passcode to access my private health information through an encrypted e-mail.

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

Signature of Patient, Parent, Guardian, or Personal Representative

Date

Doctible (Texting Platform)

We utilize a HIPAA compliant, encrypted patient-communications platform “Doctible” to text our patients. Utilizing this platform, we will text you your appointment information. As a patient, you may use our patient communication platform to text Dr. Lang questions about your healthcare, including private-protected healthcare information from 7AM to 9PM daily. He will respond by text on that platform. The Telephone Consumer Protection Act was created to protect consumers (patients) from unsolicited telemarketing messages (both phone calls and texts). On July 10, 2015, the FCC issued a new Declaratory Ruling/ Order which clarified and expanded the health care exemptions to cover wireless/ cellphones, permitting healthcare providers to place artificial/ prerecorded voice and text messages to cellphones, without the consumers’ prior express consent, written or otherwise, to convey important “health care messages” as defined and covered by HIPAA. Healthcare messages include messages relating to appointments and exams, confirmations and reminders, wellness checkups, pre-registration instructions, pre-operative instructions, post discharge follow-up, and home healthcare instructions.

I understand that even though “Doctible” is a certified HIPAA protected platform, my private cellphone is at risk for security breaches. I understand that if I ask Dr. Lang or any representative of Dr. Lang and New Orleans Podiatry Associates, I accept the responsibility that my personal and private health information will be put at risk. This includes any questions initiated from Dr. Lang, his representatives, and any representatives of New Orleans Podiatry Associates. For example, when Dr. Lang texts you after a visit to ask if you have any questions, any questions you ask of him will be answered; that exchange may not be protected on your cellphone or device. I understand that if I ask any questions of Dr. Lang, his representatives, or representatives of New Orleans Podiatry Associates, through “Doctible”, I do so with the understanding that my protected and private healthcare information may be at risk.

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

Signature of Patient, Parent, Guardian, or Personal Representative

Date

To Be Completed by NOPA Team Associate:

My Questions regarding New Orleans Podiatry Associate’s policy regarding my private health information were answered by:

NOPA Team Member:

Date

PATIENT RESPONSIBILITY

According to industry standards, New Orleans Podiatry Associates (NOPA) will file your medical claims for all applicable medical services and appliances rendered to you by our physicians. As a courtesy to our patients, this office will also send medical claims, letters, X-rays, and any other necessary information to your insurance carrier for the reimbursement of those charges.

As your insurance policy is a contract made between you and your insurance carrier, you, the patient, are responsible for monitoring the use of your policy's benefits and for remaining within your yearly maximum covered benefit allowances. In order to minimize confusion about financial responsibilities, it is the responsibility of you, the patient, to understand your insurance benefits, deductible responsibility, and co-pay obligations.

Prior to your visit, a NOPA insurance specialist will call your insurance carrier to obtain your policy information, however, that information is not always accurate. New Orleans Podiatry Associates and its representatives are not authorized to quote your medical benefits to you, and will only share with you the benefit information given to us by your insurance company. We make every effort to know how your insurance carrier will cover your care during your visit with our office, however, often the policy information we receive from insurance carriers is not accurate. It is your responsibility to call your insurance carrier before receiving treatment with this office to insure we are a provider for your insurance play, and to learn for yourself how you will be covered for your visit.

In all cases, if your insurance carrier places your treatment 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.

According to Louisiana law, insurance companies should respond to medical claims within thirty (30) days of receiving a claim. If we have not heard from your insurance company within 30 days, we will contact your insurance provider to investigate.We will also contact you, to request that you also call your insurance provider, as policy holders tend to have more influence with their insurance provider than do healthcare providers. Afer forty-five (45) days from the date of treatment, any remaining balance with any of our physicians for unpaid insurance claims (c.g. rejected, denied, or partial payments) will be your personal obligation.

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.

Co-payments, co-insurances, deductible responsibilities are due at time of service. If you choose to use a debit or credit card to pay for services, a 3% service charge will be placed to your responsibility. If you do not have your insurance card with you during your visit, you will be responsible to pay for your visit and services when rendered.

I hereby give my consent for the physicians and team of New Orleans Podiatry Associates to use and disclose protected health information about me, carry out treatment, bill insurance carriers, and to conduct healthcare operations.Additionally, I consent to New Orleans Podiutry Associates contacting me by email, through text, or by calling, including Ieaving messages on voicemail or in person for the following: appointments, appointment reminders or rescheduling, the scheduling of laboratory tests or regarding laboratory results, information related to treatment. and information related to billing.

Patient's Signature

Date

To Be Completed by NOPA Team Associate:

My questions regarding New Orleans Podiatry Associates insurance and billing policies were answered By NOPA team Member:

Date

Your information will be encrypted.