MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY

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1 MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY Dear Patient, Thank you for choosing Michael K. Block, DPM, LLC for your podiatric needs. We value our relationship with you and would like to tell you about the financial aspects of our services. Some of the information outlined within this policy include our obligations to comply with insurance, Federal, Privacy and Fair Collections Acts. Your financial responsibilities related to your healthcare are included as well. Red Flags Rule The Federal Trade Commission developed a set of rules to protect consumers against identity theft. In order to protect your identity we require a photo ID & Insurance Cards at each visit. HIPAA In compliance with HIPAA regulations, we are unable to discuss details of services rendered or to produce an itemized bill for any parties that are not the patient, unless authorized in writing by the patient. Medical Fees and Payments Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. Forms Completion We charge $15 for the completion of, but not limited to, any disability or FMLA paperwork. Missed or Canceled Appointments As a courtesy to other patients who need to be seen, if you need to cancel your appointment please call at least 24 hours in advance. There will be a fee of $55 charged to your account for any missed appointments. Excessive missed and canceled appointments will result in dismissal from our practice. Returned Checks and change of Insurance Non-Sufficient (NSF) are subject to a $35 fee (in addition to any fees charged by your bank). Cash, money orders, and credit card payments will be the form of accepted payment after an NSF fee. You must inform the front office of any insurance changes, authorizations/referral requirements. In the event the office is not informed you will be responsible for any charges denied.

2 Self Pay Patients Our practice will do our very best to give you an estimate of what will be due at time of service. Sometimes it is medically necessary to add services during your visit. When this occurs, our Providers will notify you of the service and cost. Payment for all services rendered will be due the same day treatment is provided. Minor Patients Parent(s) or guardian(s) accompanying a minor for medical services are responsible for providing insurance information and payment of the services rendered to the minor child. Non-Payment of Outstanding Accounts When there is a balance on your account we mail out your first statement with 30 days to pay that amount. If that amount is not received within 30 days, a second and final statement will be sent indicating if payment is not received within 15 days, your account will be referred to a collection agency. Once this account is received by the agency a $20 collection fee will be added to the unpaid balance. In some instances, financial constraints cause you to not be able to pay the balance in full within the timeframe expected by our office. If you contact our office prior to the account being sent to collection, our office will make every effort to work with and develop a plan to assist you in paying your outstanding balance. Referrals and Benefits As our patient, you are responsible for all authorizations/referrals needed from your PCP for specialty services to be rendered in this office. When you are in need of having any kind of durable medical equipment (DME) dispensed to you for the treatment of your specific condition, we will call your insurance to verify benefits. If there is a deductible or a co-insurance that is due for that specific DME, payment will be due at the time of service. Although we do everything to ensure the information given by your insurance company in regards to your benefits has been accurately quoted, it is only verification of benefits and not a guarantee of payment from your insurance company. If your insurance company denies this claim, it will be your responsibility to pay for that service in full. I,, have both read and fully understand the Financial Policy described. Please Print your name) I further understand that my signature below signifies that I accept the terms as set forth in this agreement. Signature of Patient or Financially Responsible Party Witness Date Date

3 Michael K. Block, DPM, LLC 3401 Box Hill Corporate Center Drive Suite 201 Abingdon, Maryland (P) (F) PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: DATE OF BIRTH: / / AGE: SEX: M F LAST FIRST MI HOME ADDRESS: CITY/STATE: ZIP: HOME PHONE #: ( ) - MAY WE LEAVE A MESSAGE? YES NO WORK PHONE #: ( ) - YES NO CELL PHONE #: ( ) - YES NO PRIMARY LANGUAGE: YES NO Social Security Number RACE: ETHNICITY: For patients 65 and older do you have a living will or someone who makes decisions for you? YES IF YES, NAME: RELATIONSHIP: PHONE #: ( ) - EMERGENCY CONTACT: RELATIONSHIP: PHONE #: ( ) - PRIMARY CARE DOCTOR: Last Visit PHARMACY: LOCATION: PHONE #: ( ) - IS THERE A FAMILY MEMBER OR OTHER PERSON YOU WOULD LIKE FOR US TO SHARE YOUR MEDICAL INFORMATION? YES NAME(S) NO WHO IS RESPONSIBLE FOR PAYMENT? RELATIONSHIP TO PATIENT? ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - WHO REFERRED YOU TO US? INSURANCE INFORMATION PRIMARY INSURANCE COMPANY NAME: ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURED NAME: DATE OF BIRTH EMPLOYER CONTRACT # GROUP # NO

4 PATIENT NAME: DATE OF BIRTH: / / SECONDARY INSURANCE COMPANY NAME: ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURED NAME: DATE OF BIRTH EMPLOYER CONTRACT # GROUP #

5 PATIENT NAME: DATE OF BIRTH: / / PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE HOW OFTEN DO YOU TAKE? ALLERGIES: MEDICATIONS ANESTHESIA FOODS TAPE LATEX SHELLFISH IODINE OTHER NONE KNOWN Your Past Medical History Bleeding Trouble/Blood Clots N Y Neuropathy N Y Cancer N Y Current A1C date and results Coronary Heart Disease N Y Diabetes N Y Heart Trouble N Y Hypertension N Y Strokes/TIA's/mini strokes N Y SOCIAL HISTORY MARITAL STATUS: SINGLE MARRIED PARTNERED SEPARATED DIVORCED WIDOWED USE OF ALCOHOL: NEVER NO LONGER USE HISTORY OF ALCOHOL ABUSE CURRENT USE - TYPE RARE OCCASIONAL MODERATE DAILY USE OF TOBACCO: NEVER USE OF RECREATIONAL DRUGS: NEVER QUIT HOW LONG AGO? SMOKE PACKS/DAY FOR YEARS QUIT HOW LONG AGO? TYPE CURRENT USE - TYPE RARE OCCASIONAL MODERATE DAILY EMPLOYER: OCCUPATION: HOW MUCH ARE YOU ON YOUR FEET AT WORK? 10% 25% 50% 75% 100% DO OTHERS DEPEND UPON YOU FOR THEIR CARE? CHILDREN AGE(S) PET(S) WHAT KIND? ELDERLY OR DISABLED FAMILY MEMBER OTHER EXERCISE: NEVER RARE OCCASIONAL WEEKLY SEVERAL TIMES A WEEK DAILY TYPES OF EXERCISE: Caffeine Use No Yes cups per day (Coffee, Tea, Colas FAMILY HISTORY DIABETES: TYPE 1 or 2 CANCER HEART DISEASE HIGH BLOOD PRESSURE STROKE CORONARY ARTERY DISEASE THYROID DISEASE RHEUMATOID ARTHRITIS

6 PATIENT NAME: DATE OF BIRTH: / / PLEASE LIST ALL PRIOR SURGERIES: TYPE OF SURGERY DATE TYPE OF SURGERY DATE HAVE YOU HAD ANY OF THE FOLLOWING WITHIN THE LAST 30 DAYS? General: None Fever, Chills, Night Sweats, Fatigue, Weight Gain, weight Loss, Poor Appetite Eyes: None Blindness, Chage in Vision, Inflammation, Poor Vision Ear/Nose: None Hearing Loss, Ringing in Ears, Nosebleeds, Hoarseness, Bleeding Gums Respiratory: None Cough, Wheeze, Shortness of Breath, Coughing up Blood Cardiovascular: None Abnormal EKG, Chest pain, Shortness of Breath, Irregular Heartbeat GI: None Abdominal Pain, Nausea, Vomiting, Blood in Stool, Black Stools, Heartburn, Diarrhea, Constipation Urinary: None Blood in Urine, Frequency, Prostate or Testicular Problem, Heavy Menstruation Muscle: None Back Pain, Broken Bones, Disc Problems, Arthritis, Swollen Joints Integumentary: None Rash, Itching, Tattoos, Skin Infections, Recurrent Boils Neurologic: None Headaches, Seizures, Chronic Numbness, Dizziness, Weakness in Arms/Legs Psychiatric: None Depression, Anxiety, Abnormal Sleep Hematologic: None Easy Bruising, Blood Clots, Transfusions Endocrine: None Goiter, Thyroid Problems, Diabetes CURRENT PROBLEM WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY? WHERE IS THE PAIN/PROBLEM LOCATED? PLEASE MARK ON THE PICTURES BELOW. LEFT FOOT RIGHT FOOT TOP OF FOOT BOTTOM OF FOOT BOTTOM OF FOOT TOP OF FOOT

7 PATIENT NAME: DATE OF BIRTH: / / HOW LONG AGO DID THIS PROBLEM FIRST START? DAYS / WEEKS / MONTHS / YEARS DID YOUR PAIN OR PROBLEM: BEGIN ALL OF A SUDDEN GRADUALLY DEVELOP OVER TIME HOW WOULD YOU DESCRIBE YOUR PAIN? NO PAIN SHARP DULL ACHING BURNING RADIATING ITCHING STABBING OTHER HOW WOULD YOU RATE YOUR PAIN ON A SCALE FROM 0 TO 10? (PLEASE CIRCLE) (NO PAIN) (WORST PAIN POSSIBLE) SINCE THE TIME YOUR PAIN OR PROBLEM BEGAN, HAS IT: STAYED THE SAME BECOME WORSE IMPROVED WHAT MAKES YOUR PAIN OR PROBLEM FEEL WORSE? WALKING STANDING DAILY ACTIVITIES RESTING DRESS SHOES HIGH HEELS FLAT SHOES ANY CLOSED TOE SHOE RUNNING OTHER WHAT MAKES YOUR PAIN OR PROBLEM FEEL BETTER? WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM? HOW HAS THIS PROBLEM AFFECTED YOUR LIFESTYLE OR ABILITY TO WORK? WAS THIS PROBLEM CAUSED BY AN INJURY? YES (DESCRIBE) NO IF YES, WAS IT A WORK-RELATED INJURY? YES NO TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS. PRINT NAME OF PATIENT, PARENT OR GUARDIAN IF OTHER THAN PATIENT, RELATIONSHIP TO PATIENT SIGNATURE OF DOCTOR DATE SIGNATURE DATE

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