Westside Dermatology

Westside Dermatology
PERSONAL INFORMATION
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Primary Care Physician
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EMERGENCY CONTACT

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INSURANCE INFORMATION
Primary Insurance Company*
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HIPAA PRIVACY ACT
I hereby acknowledge that I read and/or recieved a copy of this medical practice's Notice of Privacy Practices. If not signed by patient, please indicate relationship.
Patients Full Name*

First NameLast Name
Patient's Signature*

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Relationship to Patient
ADVANCED 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?*

YESNO
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 payers and/or 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/or dependents. I understand that if my insurance requires a referral and the referral is NOT on file in our office, I will be considered a self-pay patient.

Payment is expected at the time of service.

I understand that a fee will be charged for any missed appointments that are not canceled prior to scheduled time.

Cancellation Fees:
- $100 Office Appointment - 24 hours
- $100 Surgical Appointment per Line - 72 hours
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Date*

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120 Meadowcrest Street, Suite 430, Gretna, LA 70056 - Phone: 504-391-7620 Fax: 504-391-7624
Should be Empty:

PERSONAL INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

HIPAA PRIVACY ACT

ADVANCED DIRECTIVES

AUTHORIZATION, RELEASE, AND FINANCIAL RESPONSIBILITY