Liberty Doctors, LLC

Liberty Doctors Established Patients Annual Agreement Form

Please fill out this form completely. The following information will help us in providing you the best medical care and treatment possible. If you have any questions, please contact your Liberty Doctors office. Thank you and we look forward to seeing you!

Patient Information:

First Name * Middle Initial * Last Name: * Date of Birth * SSN * Sex * Mailing Address * City * State * Zip Code * Cell Phone * Home Phone Email Address

Additional Information

Race * Ethnicity * Preferred Language * Emergency Contact Name * Emergency Contact Number * Who is your Primacy Care Provider (PCP)? *

Responsible Party

Complete this section if the patient is a minor. If the patient is a minor (under the age of 18), the parent or guardian will be listed as the guarantor.

First Name Last Name Date of Birth Relationship to Patient Address (If different from patient)

Primary Insurance Information:

Are you self-pay? * Primary Insurance Name Policy ID Group ID Policy Holder's Name Policy Holder's Date of Birth Policy Holder's SSN * Patient Relationship to Policy Holder

Secondary Insurance Information:

Secondary Insurance Name Policy ID Group ID Policy Holder's Name Policy Holder's Date of Birth Policy Holder's SSN Patient Relationship to Policy Holder

Medical History:

List ALL medications you are currently taking (including over the counter and vitamins/supplements)

Medications

List any ALLERGIES

Allergies Please check all that apply Type of Cancer: Other:

Social History:

Do You Smoke * How many cigarettes per day? Any other forms of tobacco? * List: Do you drink alcohol? * How often? Do you use any illicit drugs? * List:

Family History:

Does anyone in your family (living or deceased) have the following:

Please check all that apply Other:

Surgical History

Please select/list all surgeries:

Please check all that apply: Other:

Assignment of Benefits & Release of Information:

I hereby authorize Liberty Doctors (LD) to release my medical information to facilitate payment and coordination of care for rendered services. I authorize payment from my insurance company (if applicable) be assigned to LD.I understand that I am ultimately responsible for the balance on my account.

I authorize the release of all medical information necessary for LD to meet State and Federal reporting requirements. If receiving medical services for employment, I authorize the release of the results of my exam to my employer.

I authorize LD to obtain all of my medication/prescription history when using any electronic system to prescribe medication. I acknowledge that I retain the right to review LD Notice of Privacy Practices in the office upon request.

Billing and Payment:

Liberty Doctors participates with many, but not all insurance plans. It is your responsibility to contact your insurance company to verify that we participate with your plan and the physician you will be seeing is in network with them. It is also your responsibility to provide accurate insurance information prior to the service. If you do not have your up to date insurance information, we will reschedule your appointment or classify your appointment as self-pay. Telehealth services may not be covered by all insurance plans. If your insurance does not cover the Telehealth visit, you will be considered self-pay and our published self-pay fee will apply. Non-covered Telehealth visits will be the patients responsibility.

Telehealth Consent:

Telehealth involves the use of electronic communications to enable health care providers to provide patient care through the means of live two-way audio and/or video. The purpose of this form is to obtain your consent to participate in a Telehealth consultation for various medical conditions/illnesses. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:Patient medical records, Medical images, Live two-way audio and/or video and Output data from medical devices and sound and video files.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the Telehealth consultation.

During the Telehealth consultation: Details of your medical history, examinations and tests will be discussed using interactive video and/or audio, A virtual examination may take place, Other medical professionals such as Medical Assistants and/or Scribes may be present during the visit to assist the provider and Photographs may be taken of you during the service. In an emergency, it is the responsibility of the Telehealth provider to direct the patient to emergency medical services, such as an emergency room. The Telehealth provider may also discuss and advise with the patients local provider (if applicable). The Telehealth providers responsibility will end upon the termination of the Telehealth connection.

As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. The session may be discontinued by the patient and/or the provider if the video conference connection is not adequate for the situation.

You may withhold or withdraw consent to the Telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdraw of any program benefits to which you would otherwise be entitled.

Certification Statement:

Today's Date *