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Carolina Family Medicine COVID-19 Patient Screening Questionnaire Carolina Family Medicine Informed Consent Carolina Family Medicine New Patient Form Charles Towne Pediatrics COVID-19 Patient Screening Questionnaire Charles Towne Pediatrics Informed Consent Charles Towne Pediatrics New Patient Form Charleston Adults and Geriatrics COVID-19 Patient Screening Questionnaire Charleston Adults and Geriatrics Informed Consent Charleston Adults and Geriatrics New Patient Form Daniel Island Family Medicine COVID-19 Patient Screening Questionnaire Daniel Island Family Medicine Informed Consent Daniel Island Family Medicine Medicare AWV Form Dr. Heather Dawson- Liberty Doctors COVID-19 Patient Screening Questionnaire Dr. Heather Dawson- Liberty Doctors Informed Consent Dr. Heather Dawson- Liberty Doctors New Patient Form Dr. Heather Dawson- Medicare AWV Form Dr. Jeffrey Akhtar COVID-19 Patient Screening Questionnaire Dr. Jeffrey Akhtar- Liberty Doctors Informed Consent Dr. Jeffrey Akhtar- Liberty Doctors New Patient Form Dr. Laura Lee Kinney Medicare AWV Form Dr. Laura Lee Kinney- Liberty Doctors COVID-19 Patient Screening Questionnaire Dr. Laura Lee Kinney- Liberty Doctors Informed Consent Dr. Laura Lee Kinney- Liberty Doctors New Patient Form Dr. Monica Lominchar- Liberty Doctors COVID-19 Patient Screening Questionnaire Dr. Monica Lominchar- Liberty Doctors Informed Consent Dr. Monica Lominchar- Liberty Doctors New Patient Form Family First Medical Care COVID-19 Patient Screening Questionnaire Family First Medical Care Informed Consent Family First Medical Care Medicare AWV Form Family First Medical Care New Patient Form Hope Clinic- Moncks Corner Informed Consent Hope Clinic- Moncks Corner COVID-19 Patient Screening Questionnaire Hope Clinic- Moncks Corner New Patient Form Hope Clinic- North Charleston COVID-19 Patient Screening Questionnaire Hope Clinic- North Charleston Informed Consent Hope Clinic- North Charleston New Patient Form Liberty Doctors COVID-19 Patient Screening Questionnaire Liberty Doctors Informed Consent Liberty Doctors Medicare AWV Form Liberty Doctors New Patient Form Medicare AWV Form Mobile Medical Consultants Informed Consent Mobile Medical Consultants Informed Consent Mobile Medical COVID-19 Patient Screening Questionnaire Mobile Medical New Patient Form North Berkeley Family Care COVID-19 Patient Screening Questionnaire North Berkeley Family Care Medicare AWV Form North Berkeley Family Care New Patient Form Simple Medicine COVID-19 Patient Screening Questionnaire Simple Medicine Informed Consent Simple Medicine New Patient Form South Strand Urgent Care COVID-19 Patient Screening Questionnaire South Strand Urgent Care Informed Consent Springhall Family Practice COVID-19 Patient Screening Questionnaire Springhall Family Practice Informed Consent Springhall Family Practice Medicare AWV Form Springhall Family Practice New Patient Form Tiffany Pediatrics COVID-19 Patient Screening Questionnaire Tiffany Pediatrics Informed Consent Tiffany Pediatrics Informed Consent Tiffany Pediatrics New Patient Form Viduya Family Practice COVID-19 Patient Screening Questionnaire Viduya Family Practice Informed Consent Viduya Family Practice Medicare AWV Form Viduya Family Practice New Patient Form
Dr. Heather Dawson- Liberty Doctors New Patient Form

Liberty Doctors Telehealth New Patient Registration 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:

Additional Information

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.

Primary Insurance Information:

Secondary Insurance Information:

Medical History:

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

List any ALLERGIES

(If Applicable)
(Not Listed Above)

Social History:

Family History:

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

Surgical History

Please select/list all surgeries:

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:

* Required field