Patient Registration

Reason for today’s visit:______________________________________________________________________

Patient Name (Last):_____________________________(First):________________________(Middle):_________

Address:_________________________________Apt.#:________City:______________State______Zip:________

Phone (Primary):________________________Phone (Secondary):_______________________DOB:___________

Social Security#:_________-_________-_________    __Male ‪ __Female      Marital Status: ‪__M  ‪__S  ‪__D  ‪__W

Patient Employer:____________________________Address:_________________________________________

Work Phone:________________________________Occupation:________________________________________

Work Status:  ‪__Employed  __‪Not Employed  __‪Retired  __‪Student

Primary Care Doctor:___________________________________________________________________________

EMERGENCY CONTACT:___________________________________Phone:_____________________________

Relationship To Patient:____________________________

How will the bill be paid today? ‪__Cash   ‪__Check   ‪__Credit Card   __Debit Card   ‪__Insurance   ‪__Work Comp

Do you have a living will?   YES   NO    Would you like information on a living will?   YES   NO

May we have your permission to contact you by telephone in follow-up to today’s visit?   YES   NO

I certify that the information provided pertaining to my health insurance coverage is true and correct. I authorize that payment for services rendered should be made payable to El Dorado Urgent Care and authorize release of medical information necessary to process this (these) claim(s). I have read all the terms and conditions contained in this agreement and agree to be bound by these terms and conditions.

Signature_______________________________________________________Date___________________________________________

We accept cash and personal checks for payment on your account. If you have insurance, which we do not contract with, you will be expected to make a full or partial payment on the day of your visit. If your insurance is one we do contract with, you are expected to pay your co-pay at the time of your visit.

COMMERCIAL/PRIVATE INSURANCE: As a courtesy we will be happy to file your insurance for you. You will be required to provide a copy of your insurance card and all necessary billing information. If you owe on your deductible or owe a co-pay we will need to collect that at the time of service. All insurance payments that are paid directly to you must be endorsed and paid to this office/physician. It is your responsibility to contact your insurance in the event of non-payment or discounted payments. Many private insurance companies, in an effort to set physician fees, restrict payment indicating that fees are over their “Usual and Customary” fees for this area. We have hired consulting firms to ensure our fees are comparable to that of other offices providing the same quality and level of care. We will not allow insurance companies to set our fees for us, based upon their willingness to pay.

CONTRACTED INSURANCE: We will submit a claim directly to the insurance carrier if you provide us with the necessary information. This includes a copy of your insurance card, an address to submit claims to and a telephone number allowing us to verify your coverage. You still are responsible for your payment of co-pay at the time of service and any amounts not covered by your insurance, including deductibles. If coverage is denied for any reason, you are responsible for payment of the entire balance due, based on our normal fee schedule.

            In the event El Dorado Urgent Care is not contracted with your health plan, you will be      ____________

            responsible for any out of network, coinsurance, or deductible applied.                                   Initial here

NO INSURANCE: If you do not have insurance, we expect you to pay for your visit at the time of service.

MEDICARE: We are participating providers with Medicare. We will submit your claim to your insurance. Medicare will process the payments to us. You are responsible for your deductible and any co-pays/co-insurance at the time of service.

RETURNED CHECKS: In the event your bank returns your check to our office unpaid, there will be a $25.00 return check fee charged to your account.

NON-PAYMENT: In the event your account becomes delinquent, you will be responsible not only for charges incurred but also any costs involved in collection on your account. These include but are not limited to interest charges, re-billing fees, court costs, attorney fees, and collections costs. A collection agency may be used to collect on delinquent accounts. Insurance benefits are a matter between you and your insurance company. You are ultimately responsible for the payment on your account.

If you have any questions regarding our payment policies, please ask us before your visit. Thank You!

I have read and understand the payment policies set forth and have been given opportunity to ask questions about this policy. I understand my responsibility for payment of my account with El Dorado Urgent Care and have provided to the best of my ability the information requested accurately and completely.

Authorization for Medical Testing/treatment: I, undersigned, consent to the procedures which may be performed during this outpatient visit, including emergency treatment and transfer, and which may include but are not limited to laboratory procedures, x-ray examinations, diagnostic procedures, medical, nursing treatment or procedures rendered to me under the general and special instructions of the physician(s) caring for me.

Personal Valuables/Belongings: The Urgent care strongly encourages all patients to make arrangements for the security of personal valuables/belongings. The Urgent Care will not be responsible for the security of personal valuables/belongings and cannot be held liable for the loss or damage to the same. In addition, the Urgent Care shall not be liable for loss or damage to any personal property such as bridgework, dentures, eyeglasses, or clothing, which is retained in the possession of the patient during his/her visit.

Patient Rights and Responsibilities: I have been offered information regarding patient rights and responsibilities.

______Yes ______No

________________________________________________                        ___________________________

SIGNATURE (PATIENT, PARENT OR GUARDIAN)                                  Date