WESTSIDE DERMATOLOGY

PERSONAL INFORMATION:

Name:______Date of Birth______Sex: M or F

Street Address:______

Cell Phone______Home Phone:______Email:______Do You Have A Primary Care Physician:? Yes_____ No _____ Name:______

Referred By: How Did You Hear About Our Office?______

INSURANCE INFORMATION:

PRIMARY INSURANCE COMPANY:______GRP/MEM ID:______

Insured/Party Responsible:______Date of Birth:______

Social Security #:______Relationship:______

Address (if different from Patient)______

Employer ______Occupation:______

SECONDARDY INSURANCE COMPANY:______GRP/MEM ID: ______

Insured/Party Responsible:______Date of Birth:______

Social Security #:______Relationship:______

Address (if different from Patient)______

Employer ______Occupation:______

EMERGENCY CONTACT – Please list below someone we may contact in case of an emergency:

Name:______Phone:______Relationship:______

HIPAA PRIVACY ACT:

I hereby acknowledge that I read and/or received a copy of this medical practice’s Notice of Privacy Practices. If not signed by patient, please indicate relationship:

Print Patient’s Name:______Relationship:______

Patient’s Signature:______

ADVANCE DIRECTIVES: Louisiana Law recognizes two (2) types of advance directives: 1) Declaration (Living Will); and 2) A Power of Attorney . Do you have an Advance Directive in place? Yes or No (circle one)

AUTHORIZATION, RELEASE AND FINANCIAL RESPONSIBILITY: I authorize the release of any information, including the diagnosis and the records of any treatment rendered to me or my dependents during the period of such care to third party payors and/or other health practitioners. I authorize and request my insurance company to pay directly to the doctor’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf and/ordependents. I understand that If my insurance requires a referral and the referral is not on file in our office I willbe considered a self-pay patient. Payment is expected at the time of service. I understand that if I do not have a credit card number of file in the office a monthly billing fee of $5.00 will be charged to my account if balance is due. I understand that a fee will be charged for any missed appointments that are not cancelled within 48 hours (2 BUNIESS DAYS). FEES: $50 Missed Appointment, $50 per Surgical Line.

Signature:______Date:______

Medications/Allergies

Medications:______

______

______

______

______

Allergies to medications, latex, bandaids, suture material:______

______

______

Previous surgeries:______

______

Any history of complications of surgeries— e.g. bleeding, abnormal scarring______

______

______

Is there any family history of Melanoma, Skin Cancer, or Adnormal Moles?______

______

Please circle below if you have been diagnosed with, suffered from, or experienced any of the following:

Hearing Problems / Elevated Cholesterol / Artificial Heart Valve / Melanoma
Cancer / Diabetes / Heart Pacemaker / Hives
Cataracts / Thyroid Disease / Unusual Hair Loss / Seizures
Genital Herpes / Lung Disease / Stroke / HIV (AIDS Virus)
Hay Fever / Migraines / Do/Have Smoked / Asthma
Arthritis / Hypertension / Drink Alcohol / Fever Blisters
Heart Disease / Gout / Heart Murmur / Peptic Ulcer
Mental Illness / Irregular Pulse / Colitis / Depression
Eczema / Jaundice / Tuberculosis / Psoriasis
Hepatitis / Allergy Non-Drug / Chronic Rash / Kidney Stone
Blood Transfusion / Abnormal Moles / Prostate Problems / Easy Bleeding
Skin Cancer / Anemia / Artificial Joints / Abnormal Scars
Lupus / Defibrillator / Acne / Joint replacement

Preferred Pharmacy:______Pharmacy Phone Number:______

Signature:______Date:______

CREDIT CARD POLICY

(Effective January 1, 2015)

At Westside Dermatology, we require keeping your credit or debit card on file as a convenient method of payment for the portion of services that your insurance doesn’t cover, but for which you are liable. Without this authorization, a billing fee of $5.00 will be added to your account for any balances that we must attempt to collect through mailing monthly statement.

  • A receipt will be kept in your chart. You may request a copy of your receipt at any time.
  • We will NOT call you prior to charging your card.

Your credit card information is kept confidential and secure and payments to your card are processed only after the claim has been filed and processed by your insurer, and the insurance portion of the claim has paid and posted to the account.

    

I authorize Westside Dermatology to charge the portion of my bill that is my financial responsibility to the following credit or debit card:

☐Amex ☐Visa ☐Mastercard ☐Discover

Credit Card Number ______CVC:______

Expiration Date _____ / _____ / _____

Cardholder Name ______

Signature ______

Billing Address ______

City ______State______Zip ______

120 Meadowcrest St., Ste. 160, Gretna, LA 70056 – Phone: 504-391-7620 Fax: 504-391-7624

UPDATED:______UPDATED:______UPDATED:______