New Patient Form

NEW ORLEANS PODIATRY ASSOCIATES

Please correct the errors described below.

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 INFORMATION

PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT

PODIATRIC HISTORY

MEDICAL HISTORY

Please indicate if you have had any of the following:

MEDICATIONS

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

ALLERGIES

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

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

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

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

To Be Completed by NOPA Team Associate:

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

Your information will be encrypted.

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