Dimitri Dermatology

Dimitri Dermatology
Elizabeth Dimitri, D.O. Kate McDonald, M.D.
Janice Birkhoff, NP
Marilyn DiMarco, NP
Dear Patient:
Welcome to Dimitri Dermatology! Our staff is dedicated to providing quality service for
our patients. We can not do it alone; we need your assistance. You are an important member of
your healthcare team.
In trying to meet the needs of our community, we are working hard to schedule patients
in a convenient and timely manner. However, waiting is inevitable. To this end, we want you to
be aware of several important office policies that will be enforced:
1. Arrival Time
In an effort to ensure that every patient is seen as soon as possible, we ask that Established
Patients arrive 15 minutes before the actual appointment time. We also ask that New Patients
arrive 30 minutes before the appointment time. Arriving prior to your actual appointment will
allow us to complete any necessary paperwork. Patients are seen by appointment time not
necessarily by arrival time. We would appreciate notification if you are running late for your
appointment due to unforeseen circumstances, please understand in these cases we may have to
ask that you reschedule your appointment if your expected or actual arrival time impacts the care
of other patients that are waiting.
2. Cancellations
If you need to cancel an appointment, we ask that you call us as early as possible and no later
than 24 hours prior to your appointment. With prior notice, we will be happy to reschedule your
appointment for the next available opening.
3. No Show
In the event that you fail to cancel your appointment and therefore a no show, you are subject
to a $15.00 fee, and will not be allowed to reschedule your appointment until the fee is paid.
4. Special Services
If you are in need of an outside special service, please let us know and we will be happy to
assist you. However, failure to cancel your appointment 48 hours before the day of your
appointment will result in a $200.00 charge. There will be no exceptions to this policy.
Thank you in advance for your cooperation and for choosing Dimitri Dermatology. If you have
any questions regarding our office policies, please give us a call (504-391-7540) and we will be
happy to assist you. We look forward to working in partnership with you to meet your
dermatological needs.
Sincerely,
Dimitri Dermatology
Home Office:
WB KN SL
Dimitri Dermatology’s
New Patient Application
DATE: ________________ HOME PH #____________________ CELL PH #___________________
PATIENT INFORMATION
NAME: _______________________________________________SS#__________________________
ADDRESS: ______________________________________________________________
CITY: _______________________________ STATE: __________ ZIP: ______________
EMAIL ADDRESS: _______________________________________________________
SEX: M___ F___ AGE_______ DATE OF BIRTH: __________________
MARRIED___ SINGLE___ DIVORCED___ WIDOWED___ MINOR___
EMPLOYER__________________________SCHOOL____________________________
WHOM MAY WE THANK FOR REFERRING YOU? ____________________________
IN CASE OF AN EMERGENCY WHO SHOULD WE NOTIFY?
NAME: ______________________________ PHONE # ___________________________ Relation: ____________
PRIMARY INSURANCE- primary card holder information
Person responsible for the account? ____________________________________
Relation to patient? ____________________ Date of Birth___________________
SS # ____________________________
Address (If different from patient’s)________________________________________
City_________________________ State____ Zip_________Ph #________________
Person responsible Employed by? ______________________ Occupation _______________
Business Address: ______________________________ Business Ph #__________________
Insurance Company_____________________________________________________
Contract/ID #________________________ Group #___________________________
ADDITIONAL INSURANCE
Is patient covered by additional insurance? Yes_____ No_____
Subscriber Name_____________________________ Date of Birth______________
SS #__________________________________
Relation to patient________________________ Ph #________________________
Address (If different from patient’s)__________________________________
City____________________________ State_______ Zip_______________
Insurance Company_____________________________________________________
Contract/ID #___________________________ Group #________________________
ASSIGNMENT INSURANCE
I certify that I, and/or my dependent(s), have insurance coverage with ______________________
(Name of Ins. Co.) and assign directly to Dr. Elizabeth M. Dimitri all insurance benefits, if any, otherwise payable to
me for services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance. I authorize the use of my signature on all insurance submissions. The above-named Doctor may use my
health care information and may disclose such information to the above named insurance company(ies) and their
agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable
for related services. This consent will end when my current treatment plan is completed or one year from this date
signed below.
____________________________________________
_____________
Signature of patient, parent/guardian/personal representative
Date
_________________________________________________
Please Print name of patient, parent/guardian/personal rep.
_______________
Relation to patient
Louisiana Department of Health and Hospitals
Authorization to Release or Obtain Health Information
(Including paper, oral, and electronic information)
Please fill out the underlined information ONLY and Sign the bottom!
Request Date (OFFICE USE ONLY):
Name:
Mailing Address:
Date of Birth:
City/State/ Zip:
Social Security Number:
I authorize:
Name: ________________________________________________________________________
Mailing Address: _______________________________________________________________
City, State, Zip Code: ___________________________________________________________
Relationship: ________________________________ Telephone Number: _________________
RELEASE Information TO or
Obtain Information FROM
(Place and “X” in the box that indicates if the information is being released OR requested)
Name: ________________________________________________________________________
Mailing Address: _______________________________________________________________
City, State, Zip Code: ___________________________________________________________
Relationship: ________________________________ Telephone Number: _________________
The purpose of this Authorization is indicated in the box (es) below. (Place an “X” in the box (es) that apply.)
Further Medical Care
Personal
Legal Investigation or Action
Changing Physicians
Research Related Treatment
Creating health information for disclosure to a third party
Other (Specify): ____________________________________________________________________________
I authorize the release of the following protected health information
(Place an “X” in the box(es) that apply to the information you want released or you want to obtain.)
Entire Record Medical History, Examination, Reports Surgical Reports Treatment or Tests
Prescriptions
Immunizations Hospital Records including Reports
Laboratory Reports
X-Ray Reports Other (Specify): ______________________________________________________________
In compliance with state and/or federal laws, which require special permission to release otherwise privileged information, please release the
following records.
Alcoholism Drug Abuse Mental Health Vocational Rehabilitation
HIV (AIDS) Genetics
Sexually Transmitted Diseases Psychotherapy notes Other: _______________________________________
This authorization shall expire on _________________________________ (date or event).
I understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date on which it was requested.
X______________________________________________________________
Signature of Individual or Personal Representative Authorized by law
_______________________________
Date
For DHH Use when Requesting Records
I am Authorized to receive this disclosure. Documentation of the above Personal Representative has been obtained.
_________________________________________________________
________________________________
Signature and Title of Agency Representative
Date
Dimitri Dermatology
Notice for the use and disclosure of health information for treatment, payment, or
healthcare operations
Privacy notice
Effective Date April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED,
DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY!
1. Uses and disclosures:
Dimitri Dermatology (a Louisiana corporation) is permitted by law to disclose the minimum necessary
personal health information of each patient to carry out treatment, payment, and health care operations of Dimitri
Dermatology. For treatment purposes, such disclosures may be made to physicians and other health care providers
as necessary to effectuate the appropriate treatment and care of patients. Personal health information may be
disclosed to the government or third party payers for the purpose of obtaining payment for services provided.
Dimitri Dermatology may also use personal health information to carry out Dimitri Dermatology’s day to day
operations such as scheduling, quality review, and appointment reminders. A list of other examples of disclosures
can be obtained by the privacy officer upon request.
2. Required Authorizations:
Dimitri Dermatology will not disclose any patient’s personal health information for any purpose aside from
payment, treatment, and health care operations, without patients authorized consent to such disclosure. Upon
request for such authorization, the patient shall have the right to refuse and/or revoke any disclosure of patient’s
personal health information.
3. Privacy Compliance:
In accordance with the privacy regulations promulgated under the Health Insurance Portability and
Accountability Act 45 CFR parts 160 and 164 (The “privacy Regulations”), Dimitri Dermatology has adopted privacy
policies regarding usage of patients’ personal health information. Dimitri Dermatology is committed to compliance
with privacy regulations and all other laws and regulations regarding patients’ right to privacy.
4. Additional Information:
For additional information regarding Dimitri Dermatology’s privacy policy or for a copy of this notice, please
contact our Privacy Officer. Dimitri Dermatology reserves the right to change this notice and make the revised and
changed notice effective for medical information that Dimitri Dermatology already has about you, as well as any
information Dimitri Dermatology receives in the future. We will post a copy of the current notice in the office. The
notice will contain the effective date.
The following signature acknowledges that I have received notification of my privacy rights concerning the use and
disclosure of protected health information as defined by the Privacy Regulations.
Signature: ____________________________________
The following signature acknowledges that I have received a copy of this Notice:
Signature: ____________________________________
Dimitri Dermatology
Resume of Contract
**Please initial each blank line of the contract, and sign at the bottom**
I understand that I am entering into a contractual relationship with Dimitri Dermatology for professional care. I
further understand that merit less and frivolous claims for medical malpractice have an adverse effect upon the
cost and availability of medical care, and may result in irreparable harm to a medical provider.
As additional consideration for professional care provided to me by Dimitri Dermatology I,
____________________ and/or my representative agree not to advance, directly or indirectly, any false, merit
less, and/or frivolous claim(s) or medical malpractice against Dimitri Dermatology.
Additionally, should a meritorious medical malpractice case or cause of action be initiated or pursued, I,
__________________ and/or my representative agree to use ABPS board-certified expert medical witness(es) in
the same or similar specialty as Dr. Dimitri.
Furthermore, I agree that this expert witness(es) will adhere to the guidelines and/or code of conduct defined by
the specialty society for expert witnesses in the area(s) of medicine that would typically have the background
and experience to speak out on such a case. In further consideration for this, I, ____________________, agree to
the same stipulations
In addition, I, _____________________ understand that I have the rights to any attorney of my choosing, and
that any attorney I select will be an attorney licensed in the state of Louisiana, and such license will be in good
standing with the state.
I am also aware, that Dr. Elizabeth Dimitri, her associates, professional staff, and the business managing entity
maintain professional liability insurance in accordance with state law.
____________________________________
Physician
______________________________________
Patient/Guardian Signature
____________________________________
Witness
______________________________________
Date
Our Financial Policy
Thank you for choosing us as your health care provider. We are committed to your treatment being
successful. Please understand that your payment of your bill is considered a part of your treatment. The
following is a statement of our financial policy which we require you read and sign prior to any treatment.
All patients must complete our Information and Insurance form before seeing the doctor.
Regarding Insurance
We may accept assignment of insurance benefits. The balance is your responsibility whether your
insurance company pays or not. We cannot bill your insurance company unless you give us your insurance
information. Your insurance policy is a contract between you and your insurance policy. We are not a party
to the contract. If your insurance has not paid your account in full within 45 days, the balance will be
automatically transferred to you. Please be aware that some and perhaps all, of the services provided may
be non-covered services and not considered reasonable and necessary under the Medicare Program and/or
other medical insurance.
Regarding insurance plans where we are a participating provider:
All co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to
a plan where we are not a participating provider, refer to the above paragraph.
Usual and Customary Rates
Our Practice is committed to providing the best treatment for our patients and we charge what is
usual and customary for our area. You are responsible for payment regardless of any insurance company’s
arbitrary determination of usual and customary rates.
Adult Patients:
Adult patients are responsible for payment at time of service.
Patients:
The adult accompanying a minor and the parents (or guardian) are responsible for payment.
Missed Appointments:
Unless cancelled at least 24 hours in advance, our policy is to charge for the missed appointment at
the rate of $15.00 per appointment missed. Please help us serve you better by keeping scheduled
appointments.
FULL PAYMENT IS DUE AT TIME OF SERVICE
WE ACCEPT CASH, CHECKS, AND CREDIT CARDS
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.
I have read and agree to this Financial Policy
Patient/ Parent/ Guardian Signature: ___________________________
Patient’s name: _______________________
Date: ___________
Dimitri Dermatology
120 Meadowcrest Street
Suite 235
Gretna, LA 70056
PH: 504-391-7540
FAX: 504-3917543
105 Medical Center Drive
Suite 206
Slidell, LA 70461
PH: 985-643-4575
FAX: 985-643-4513
3715 Williams BLVD.
Suite 100
Kenner, LA 70065
PH: 504-465-4550
FAX: 504-465-8590
I, _______________________________________ have received a copy of this office’s Notice of Privacy
Practices.
Signature __________________________________ Date ______________
THIS IS TO AUTHORIZE ELIZABETH DIMITRI, D.O., AND HER STAFF TO SPEAK WITH MY:
(Who may we speak with when calling?)
_____________________________,
Name
________________________________
Relation
_____________________________,
Name
________________________________
Relation
TO DISCUSS WITH THEM MEDICAL TREATMENT I HAVE BEEN OR WILL BE RECEIVING FROM
THIS CLINIC AND OTHER MATTERS RELATED TO SUCH MEDICAL TREATMENT OR MEDICAL
CARE OR PERSONAL INSTRUCTIONS.
THIS AUTHORIZATION SHALL REMAIN IN EFFECT UNTIL SUC TIME AS IT IS WITHDRAWN BYU
ME, IN WRITING, REGUARDLESS OF THE DATE SIGNED.
__________________________________
Patient Signature/Authorized Person
_________________________
Date
For Office Use Only
We attempted to obtain written acknowledgement of receipt or our Notice of Privacy Practices, our acknowledgement
could not be obtained because:
(
(
(
(
)
)
)
)
Individual refused to sign
Communication barriers prohibited obtaining the acknowledgement
An emergency situation prohibited us from obtaining acknowledgement
Other (Please specify)
Witness_________________________________
Date__________________________
Dimitri Dermatology
CONFIDENTIAL
This page has 2 sides
Health History
Patient Name ______________________________________________ Today’s Date________________
D.O.B____________________________ Age________ Date of last physical_______________________
What is the reason for your visit? ___________________________________________________________
Symptoms Please check (
) symptoms you (patient) have or have had in the past year.
General
Gastrointestinal
□ Chills
□ Depression
□ Dizziness
□ Fainting
□ Fever
□ Forgetfulness
□ Headache
□ Loss of Sleep
□ Nervousness
□ Numbness
□ Sweats
□ Poor Appetite
□ Bloating
□ Bowel Changes
□ Constipation
□ Diarrhea
□ Excessive Hunger
□ Excessive Thirst
□ Gas
□ Hemorrhoids
□ Indigestion
□ Nausea
□ Rectal Bleeding
□ Stomach Pain
□ Vomiting
□Vomiting Blood
Cardiovascular
□ Chest Pain
□ High Blood
Pressure
□ Irreg. Heart beat
□ Low blood
pressure
□ Poor Circulation
□ Rapid heart beat
□ Swelling of ankles
□Varicose veins
Muscle/Joint/Bone
Pain, weakness,
Numbness in:
□Arms □ Hips
□ Back □ Feet
□ Hands □Neck
□ Legs
□ Shoulders
Conditions Please check (
□ Aids
□ Alcoholism
□ Anemia
□ Anorexia
□ Appendicitis
□ Arthritis
□ Asthma
□ Bleeding Disorders
□ Breast Lump
□ Bronchitis
□ Bulimia
□ Cancer
□ Cataracts
Eye, Ear, Nose, Throat
□ Bleeding Gums
□ Blurred Vision
□ Crossed Eyes
□ Difficulty swallowing
□ Double Vision
□ Earache
□ Ear Discharge
□ Hay Fever
□ Hoarseness
□ Loss of hearing
□ Nosebleeds
□ Persistent cough
□ Ringing in Ears
□ Sinus Problems
□ Vision- Flashes
□ Vision- Halos
Skin
□ Bruise easily
□ Hives
□ Itching
□ Change in Moles
□ Rash
□ Scars
□ Sores that won’t heal
Men Only
□ Breast Lump
□ Erection Difficulties
□ Lump in Testicles
□ Penis Discharge
□ Sore on Penis
□ Other _______________
__________________
Genito-Urinary
□ Blood in Urine
□ Frequent Urination
□ Painful Urination
□ Lack of Bladder Control
Women Only
□ Abnormal Pap smear
□ Bleeding between
periods
□ Breast Lump
□ Extreme menstrual
pain
□ Hot Flashes
□ Nipple discharges
□ Painful intercourse
□ Vaginal discharge
□ Other __________
_____________
Date of last menstrual
period:
________________
Date of last Pap smear:
____________________
Have you had a
mammogram? ____
Are you pregnant?
__________
Number of Children
_______
) symptoms you (patient) have or have had in the past.
□ Chemical Dependency
□ Chicken Pox
□ Diabetes
□ Emphysema
□ Epilepsy
□ Glaucoma
□ Goiter
□ Gonorrhea
□Gout
□ Heart Disease
□ Hepatitis
□ Hernia
□ Herpes
□ High Cholesterol
□ HIV Positive
□ Kidney Disease
□ Liver Disease
□ Measles
□ Migraine Headaches
□ Miscarriage
□ Mononucleosis
□ Multiple Sclerosis
□ Mumps
□ Pacemaker
□ Pneumonia
□ Polio
Medications List medications you are currently taking
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
□ Prostate Problem
□ Psychiatric Care
□ Rheumatic Fever
□ Scarlet Fever
□ Stroke
□ Suicide Attempt
□ Thyroid Problems
□ Tonsillitis
□ Tuberculosis
□ Typhoid Fever
□ Ulcers
□ Vaginal Infections
□ Venereal Disease
Allergies to any medications or substances
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Pharmacy Name: _____________________________
Pharmacy Phone: ____________________________
Family History fill in health information for
the patient’s immediate family
Relation
Age
State of
Health
Age at
death
Check off if the patient’s blood relatives had any of the following:
Disease
Relation to Patient
Arthritis, Gout
Asthma, hay fever
Cancer
Cause of death
Father
Mother
Brother
Chemical dependency
Diabetes
Heart disease, stroke
High blood pressure
Kidney disease
Tuberculosis
Other
Sister
Pregnancy History
Year of Birth
Sex Complications, if any
Hospitalization
Year
Hospital
Reason for hospitalization
Health Habits how often does the patient use the following:
Caffeine: __________________________
Has the patient ever had a blood transfusion? _______
If yes, please give approximate dates. _____________
___________________________________________
Serious Illness/ Injuries
Date
Outcome
Tobacco: __________________________
Street Drugs: _______________________
Other: ____________________________
Occupational Concerns check ( ) if your work
exposes you to the following:
□ Stress
□Hazardous Substances
□ Heavy Lifting
□ Other: ______________
□ Your Occupation: ____________________________
____________________________________________
To the best of my knowledge, the above information is complete and correct. I understand that it is my
responsibility to inform my doctor if I or my minor children ever have a change in health.
X______________________________________________
___
Signature of patient, parent, guardian or personal representative
X____________________________________________________
Please print name of patient, parent, guardian or personal representative
Reviewed by: ____________________________________________________
__________________
Date
___________________
Date
Date _____________________
Dimitri Dermatology
INFORMATION ABOUT ADVANCE CARE DIRECTIVES
Please fill
out_______________________
if:
Date:
you are 65 years or older
Are on People’s Health Insurance
Patient’s Name: _________________________________
DOB _________________
Advance Directives are legal documents allowing an individual to plan for their future medical care, particularly
when they are unable to make his/her own decisions. These documents (i.e. Living Will, Healthcare Proxy, and “DNR”
Do Not Recesitate) allow and individual to articulate their preference for care, in the event they become unable to
communicate such direction in the future, when faced with a terminal and/or life-threatening illness.
Advance Directives recognize the individual’s right of the decision-making in planning their own end-of-life
care. It is important to note that individuals always reserve the right to change or alter their written directions, as long
as they are capable to communicate with family and/or healthcare providers. It is only in the absence of such an ability
to communicate their preferences that healthcare professionals follow the patient’s Advance Directive Care.
It is important for all medical personnel to have knowledge of this information in your medical chart. This form
is to serve as notification of “YOUR” decision as to whether you have and ADVANCE CARE DIRECTIVE in place
and if so who will serve as your voice in the event you become incapacitated or otherwise unable to participate in your
own treatment decisions.
I DO have an Advance Care Directive in place and have chosen ____________________________, my
__________________________, as the one to make all my medical decisions.
I DO NOT have an Advance Care Directive in place; therefore I can and will make all of my medical decisions.
__________________________________
Signature of Patient
__________________
Date
_________________________________
Patient’s name PRINTED
MEDICAID RESPONSIBILITY
Please fill out if:
You have Medicaid
Medicaid only allows twelve (12) visits per year (over the age of 18) on your medical card.
Please note that if the number of office visits exceed that amount, you will be responsible for the
charges of the office visit (if a billable procedure is accomplished). MEDICAID may pay for approved
procedures.
The number of office visits remaining is indicated each time you visit our office, when we process your
card. Medicaid will normally pay a percentage of the usual and customary fees on services rendered;
therefore, you will not be billed for services.
Medicaid also does not pay for any injections for any recipient over 21 years of age; therefore, should
an adult receive an injection, they will be responsible for the charge.
Any office visits that are not paid through MEDICAID for children will be responsibility of the parent
and/or legal guardian indicated as the “responsible party”.
Any recipient needing a Community Care referral from their primary care
physician is responsible for the dates indicated on the referral. In addition, all
recipients are required to bring a copy of their referral to EVERY visit.
Medicaid will not pay for the visit if a referral is not present and your
appointment will be rescheduled for another day.
Thank you for your cooperation.
I have read the above and agree to the terms therein. I hereby acknowledge that I am the legal guardian of
______________________, the above mentioned child and agree to the terms as indicated there in. I have
received a copy of my referral, and realize that I am responsible for bringing my referral to every visit, and for
making sure that it is updated at all times.
Patient/ Parent/Guardian Signature: ____________________________ Date: ________
Patient’s Name (Please Print): ______________________________