Поиск
Рекомендуем ознакомиться
Главная > Документ
Информация о документе | |
Дата добавления: | |
Размер: | |
Доступные форматы для скачивания: | ![]() |
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
Похожие документы:
Тайны мирового правительства
Документ... George McGhee) и Клейборн Пелл (Claiborne Pell) — это всего лишь ... Aspen Institute (“Аспенский институт”) Association for Humanistic Psychology (“Ассоциация ... Canada (“Иерусалимский фонд”, Канада) Kissinger Associates (“Киссинджер ассошиейтс” — “Помощники ...