Patient FormsMichael J. Freeman, MD, PA – DocFreeman Dermatology located in Ocala & The Villages, FloridaSave time and fill out these forms prior to your initial appointmentMichael J. Freeman, MD, PA – DocFreeman Dermatology Clinic located in Ocala, FL & The Villages, FLRegistration FormPatient InformationYour Name(Required) First Middle Initial Last Your Address Street Address Address Line 2 City ZIP Code Your Date of Birth DD slash MM slash YYYY Patient SSNSexChooseMaleFemaleNon-BinaryMarital StatusChooseSingleMarriedOtherPharmacy Name and AddressHow Can We Reach You?Preferred Method of ContactEmailPhoneYour Email Address(Required) Your Phone(Required)Insured/Responsible Party InformationRelationship to PatientChooseSpouseParentGuardianName First Middle Initial Last Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneEmail EmployerDemographicsEthnicityHispanic or LatinoNot Hispanic or LatinoRaceAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteDeclinePreferred LanguageInsurance InformationPrimary Insurance NameSecondary Insurance NamePrimary Doctor/Family DoctorReferring DoctorIn Case of Emergency Contact First Last RelationshipPhoneASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.SignatureAUTHORIZATION TO RELEASE HEALTH INFORMATION:I understand that: - Once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information. - I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524). - My records are protected and cannot be disclosed without written permission - This Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department.Name First Last RelationshipPhoneAUTHORIZATION EXPIRES (UNLESS OTHERWISE NOTED THIS AUTHORIZATION WILL REMAIN IN EFFECT ONE YEAR FROM THE DATE SIGNED) NeverDate DD slash MM slash YYYY Michael J. Freeman, MD, PA - DocFreeman Dermatology staff, have permission to leave messages regarding my medical and/or financial information on my voicemail or cell phone. Yes NoRelease the following information: All Records Chart Notes Pathology Reports Operative Reports HistoryRELEASE OF INFORMATIONI understand that: - Once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information. - I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524). - My records are protected and cannot be disclosed without written permission - This Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.Signature of Patient or Legal RepresentativeDate DD slash MM slash YYYY Relationship to PatientPATIENT MEDICAL HISTORYName First Middle Initial Last Date of Birth DD slash MM slash YYYY Reason for today's visitAllergies NONE/No Known Allergies Adhesive Tape Anesthesia Aspirin Codeine Sulfa Drugs Iodine Latex PenicillinOtherHave you ever had dental anesthesia (Novocaine)?YesNoAny bad reaction?YesNoFAMILY HISTORY – Please indicate if any of your immediate relatives have had any of the following by placing an check in the appropriate box.Skin Cancer Mother Father SiblingDiabetes Mother Father SiblingHeart Problems Mother Father SiblingHypertension Mother Father SiblingStroke Mother Father SiblingThyroid Disorder Mother Father SiblingImmunization – Please indicate if you have had any of the following administered and if known list the date.Flu Shot Yes NoDate DD slash MM slash YYYY Shingles Yes NoDate DD slash MM slash YYYY Whooping Cough Yes NoDate DD slash MM slash YYYY Pneumonia Yes NoDate MM slash DD slash YYYY Tetanus Yes NoDate MM slash DD slash YYYY SOCIAL HISTORYOccupationOccupation Retired DisabledDo you drink alcohol? Yes NoHow often? Daily Weekly InfrequentlyDo you use IV drugs? Yes NoDo you use tobacco? Yes NoSmoke Yes NoPacks per dayIf yes, when did you start?Surgical History: Please list any hospitalizations, surgeries, fractures or major illnesses you have had.Have you ever been exposed to HIV (AIDS)? Yes No(Women) Are you pregnant? Yes NoDue Date DD slash MM slash YYYY Have you ever had skin cancer? Yes NoDo you have a history of any specific skin disease? Yes NoIf yes, please explainDo you have problems healing? Yes NoDo you develop keloids (scars) after surgery? Yes NoDo you bleed easily? Yes NoDo you use sunscreen? Yes NoMedical History: Have you ever had any of the following?Lungs Bronchitis Emphysema Asthma Chronic Cough Morning Cough Shortness of Breath WheezingCardiovascular High Blood Pressure Chest Pain Heart Attack Heart Murmur Irregular Heartbeat Phlebitis Inflammation of Vein Blood ClotOther Systemic Diabetes Excessive thirst/hunger Amputation Thyroid Problem Kidney Problem Dialysis Bladder Problem Frequency/Burning Convulsion, Epilepsy, Seizures, or Fainting Gastrointestinal Problems Stomach Arthritis/Joint Deformity Arthralgia Limited Motion Artificial Joint NONE of the problems listedWhen taking antibiotics: Nausea, vomiting, diarrhea Yeast InfectionMedications: List any medications you are currently takingFinancial Policy Thank you for choosing Michael J. Freeman, MD, PA – DocFreeman Dermatology for your medical care. We appreciate that you have entrusted us withyour healthcare and we are committed to providing you with the best patient care possible. Because healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you better understand your responsibilities as a patient. We will do our best to assist you with understanding your proposed treatment and in answering questions related to submitting your insurance claim for reimbursement. Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals and/or pre-authorizations. You should be knowledgeable of any deductibles, copayments and/or coinsurance.If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket expenses, and coverage limits. Insurance Coverage: Please provide us with your current insurance card at the time of each visit and notify us of any changes. We will request a copy of your insurance card to copy and keep on file for our records. Please be aware of and provide any required referrals or authorizations in advance of the appointment. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification. Our doctors belong to many insurance plans. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the costs of care. We will help you find out if you have out-of-network benefits and submit a claim to your plan on your behalf. Co-payments/Co-insurance/Deductibles: You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time of service. We accept cash, personal checks, VISA MasterCard, and Discover. Other Bills: You may receive Pathology services during your visit and there will be additional charges for these services. Self-Pay: Self-pay patients are required to pay 100% of the estimated amount due at the time of service. Non-Medical Fees: Additional fees may apply to the following: Returned Checks – There will be a $25 fee assessed on returned checks. Missed Appointments: We require a 24 hour notice of appointment cancellation. Appointments missed that are not previously cancelled will be charged a fee of $25. Late Arrivals: A patient who arrives more than 15 minutes after his/her appointment is considered a late arrival. A late arrival, not considered to be the responsibility of the Practice, will be registered and worked into the schedule as soon as possible. If the patient is more than 30 minutes late, the appointment may be rescheduled. Assignment of Benefits and Responsibility to Pay I hereby assign all medical and surgical benefits to which I am entitled. I hereby authorize and direct my insurance to issue payment directly to Daystar Skin and Cancer Center for medical services to myself and/or my dependents. I have also read and understand the financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.Name of Patient First Last Date MM slash DD slash YYYY Signature of Patient (or responsible party)HIPAA Patient Consent FormOur Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: - Protected health information may be disclosed or used for treatment, payment, or health care operations - The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice - The Practice reserves the right to change the Notice of Privacy Practices - The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions - The patient may revoke this Consent in writing at any time and all future disclosures will then cease - The Practice may condition receipt of treatment upon the execution of this Consent. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. This Consent was signed by:Patient Name First Last Date MM slash DD slash YYYY Patient SignatureRelationship to Patient (if other than patient):Witness Name – Practice Representative First Last Date MM slash DD slash YYYY Witness Signature
