Intake Form


Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

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Sex
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Race




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*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity
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Preferred Language
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Are you pregnant?
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Are you nursing?
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Have you completed an Advance Directive (living will)?
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Who referred you to our office?




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Is it limiting your activity level?
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Medical History (please check all that apply)
































































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Is your problem related to a Workman’s Comp injury or an auto/other accident?
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Social History

Do you drink alcohol?
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How often?
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Do you smoke, vape or use chewing tobacco?
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Please specify
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Do you have/have had a substance abuse problem?
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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

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Insurance Information

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HMO
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Emergency Contact

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Responsible Party (if minor patient)

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Permission to disclose relevant health information to individuals involved in my health care:

I give permission for Nola Sole Podiatry to disclose relevant information (my health status, treatment & payment arrangements) to my family members and to the individuals(s) I have listed below who are involved in my health care.
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View Privacy Policy

Consent for Treatment and Acknowledgement of Policies

For any insurance plan that requires authorization from a primary care physician (e.g. HMO, PPO, etc.) it is your responsibility (as patient or guardian) to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. Professional services are rendered and billed directly to your insurance carrier; however you, the patient/guardian, are directly responsible for services rendered by the doctor. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian.
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All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name NOLA Sole Podiatry (NOLASP) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay NOLASP directly for all professional and medical services provided by NOLASP through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to NOLASP. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.
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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.
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I acknowledge that I was provided a copy of the Notice of Privacy Practices for NOLA Sole Podiatry and I have read (or had the opportunity to read if I so choose) and understood the Notice.
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PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. NOLA Sole Podiatry has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

Please Remember: Regardless of the type of insurance or the party you feel is responsible for your bill, our agreement for treatment is with you. We will ultimately look only to you for payment of your account,
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If you are covered by managed care insurance, we will need to verify that you are currently eligible for benefits before the doctor sees you. The majority of these organizations require prior authorization for each visit and the patient is responsible for acquiring office visit authorizations.
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By signing this document I understand that I am required to have a physical copy of my insurance card and picture ID when I arrive for my appointment. Failure to have any one of these documents will result in my appointment being rescheduled. I also understand 'LA wallet' or screen shot copies of insurance cards on phones will not be accepted.
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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

 

CHANGES TO LOUISIANA MEDICAID EFFECTIVE
JANUARY 1, 2026

PLEASE READ IF YOU HAVE
UNITED HEALTHCARE COMMUNITY MEDICAID

Louisiana Medicaid will soon auto-assign many patients to a new health plan because United Healthcare is exiting the State of Louisiana effective December 31, 2025. This first assignment is made by a state algorithm which means patients do not choose their initial plan.

*IMPORTANT*
After being assigned, every patient has a 90 day window to review their new plan and decide if they want to switch to a different one.

Dr. Robertson currently accepts the following Medicaid plan:
Louisiana Healthcare Connections

Every Medicaid plan offers different benefits, provider networks, transportation options, and pharmacy coverage.

We encourage patients to:
* Review the plan they were assigned
* Make sure their preferred doctors and clinics are in network
* Check whether the assigned plan meets their family’s needs.

If your assigned plan does not fit well, you may choose another available plan within the 90 day switch window.

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