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M.D. Claiborne & Associates, LLC

Dermatology Specialists

1477 Louisiana Avenue 5740 Citrus Boulverad

New Orleans, LA. Harahan, LA.

Section I – Patient Information

Name:______________________________________________________________________________

( please print full legal name – no nicknames )

Address:___________________________________________________________________________

City:_______________ State:__________ Zip code: ___________

Home number ( )______-________ Cell phone ( )______-_________

Email address:__________________________________________

SSN:_____-_____-________ Date of Birth____/____/______ Gender: M F

Martial Status: S M W D Name of Spouse: ____________________________

Race: ____ White (non Hispanic) _____Hispanic _____Asian

____ American Indian _____ Indian _____ African American

____ Other

Place of Employment:_______________________ Job Title _______________________

Length at current job:______years _______ months

Work number ( ) ______-__________ Work Email: ______________________________

Name of person or source that referred you here today:______________________.

Section II - Minors

Parent/Guardian Name:_____________________relationship to patient:__________

Address and telephone the same? ______yes _____no

If not, address for parent/guardian:

______________________________________________________ City:___________________State:______________Zip:_______

Telephone: ( )______-____________

Please note that children under the age of 18 must be accompanied by a parent or guardian at all visits.

Please turn page over

Page 2

Section IV- Insurance

For medical record purposes, this office will make a copy of your insurance card and a

picture ID to keep on file.

Name of Primary Insurance:___________________________________

Are you covered by more than one carrier? YES NO

If so please tell us which is: primary______________________ secondary________________

Insurance holder’s name: ________________________________

Insurance holder’s date of birth: _____/_____/______

Insurance holder’s SSN: _____-____-_______

Section V – Authorizations

Do you give permission for our office to discuss your medical information with family members? Yes or No

If yes, then tell us with whom:

Name _________________________________ relationship _________________phone #_______________

Name _________________________________ relationship _________________phone #_______________

Name _________________________________ relationship _________________phone #_______________

Emergency contact name:_______________________________ relationship_______________________

Home number: ______________________ alternate number:____________________________________

May we contact you at the numbers you recorded in section I? Yes No

If not, which may we use?___________________________________________________

May we leave personal medical information on your answering machine or cell phone? Yes No

May we e-mail personal information to you? Yes No

Section VI – Office Policy

Financial- It is the policy of this office to collect all co payments due at the time of service. If a balance is due on your account,

we will send you a statement for that balance. A total of only 2 statements will be sent. If no payment is received after the second

notice, your account will be placed with an outside collection agency for settlement.

Appointments- This office is operated on an appointment only basis. We do not accept walk ins. Your time is just as important as ours. If you are

more than 15 minutes late for your scheduled appointment, we ask that you reschedule as a courtesy to others. If you need to

cancel an appointment, please call as soon as possible to let us know. Patients who continually do not show for their scheduled

appointments without calling to cancel, will be asked to find care with another dermatologist. You will be sent a certified letter

informing you of this decision.

HIPPA - We will protect your right to privacy as outlined by HIPPA laws. Brochures are available throughout this office for your convenience.

By signing below, you agree that you understand your rights under this policy.

Assignments- You agree to have all insurance payments sent directly to the doctor performing your service(s). We will file all charges as a

courtesy for you to your carrier. There are times when medical information will be requested by your carrier in order to verify and

process your charge(s). By signing below, you grant us the right to send this information on your behalf so that your charges may

be settled.

Tumor Registry This office is mandated by law to record any malignant lesions with the Louisiana Tumor registry. The information is protected

under your HIPPA rights and is not forwarded to any other agency. By signing below you agree to allow us to record this

information should it apply to you.

____________________________________________ ________/_______/________

Patient Signature Date



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