Registration Form
Patient Information
PLEASE FILL IN ALL INFORMATION REQUESTED ON THIS FORM |
| Legal First Name: Legal Last Name: |
| Email: Social Security #: |
| Address: |
| City: State: Zip: |
| Date of Birth: Gender:
M
F Marital Status:
Married Single |
| Home Phone: Cell Phone: |
| Employer: Work Phone: |
| Primary Care Giver: |
| Pharmacy: Location: |
| Emergency Contact: Contact Phone: |
| Spouse's Name (if applicable): Contact Phone: |
Reason for Visit:
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Responsible Party Information
PERSON RESPONSIBLE FOR BILL, ONLY NEED TO COMPLETE IF PATIENT IS A MINOR OR WORKERS COMP |
| Legal First Name: Legal Last Name: |
| Relationship to Patient: Social Security #: |
| Address information is same as above |
| Address: |
| City: State: Zip: |
Date of Birth: Gender: Male Female
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Insurance Coverage Information
*BRING PROOF OF INSURANCE, A PHOTOCOPY WILL ALSO BE TAKEN AT APPOINTMENT TIME* |
| Insurance Company: Subscriber Name: |
| ID: Group Number: |
| Relationship to Patient: Social Security #: |
Subscriber's Employer: Date of Birth:
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When you arrive at Urgent Care Clinic of Lincoln you will be requested to sign your consent to the following information:
Insurance and Assignment of Benefits Authorization Information
I hereby authorize treatment of the above named patient and agree to pay all charges for treatment regardless of insurance coverage or the pendency of insurance claims.
I authorize the release of all medical information to the above insurance carriers that is pertinent to my medical care and necessary to process my insurance claims. I assign all medical and surgical benefits to Urgent Care Clinic of Lincoln PC. A photocopy of this form shall be as valid as the original. I understand that I can withdraw this medical benefit assignment at any time by notifying this office in writing.
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HIPAA Consent of Privacy
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our policies and procedures pertaining to privacy of information before you sign this consent. We are required to notify you of who may be allowed to view elements of your medical record. This currently includes your insurance company, Lab Corp if we send out lab specimens for you, Advanced Medical Imaging if we send you for diagnostic imaging, you primary care physician when needed, the local emergency departments if you are transported to the emergency room for a true medical emergency, and any other medical practice that specializes in treatment of care that we refer you to. Our policies may change from time to time. If we change our policy, you may obtain a revised copy. You have the right to request in writing that we restrict specific elements of your health record. If your restrictions inhibit our ability to provide care or collect reimbursement, we are under no obligation to treat you. If we agree to any additional restrictions you request, we are bound by our agreement. By signing the HIPAA Consent of Privacy, you consent to Urgent Care Clinic of Lincoln's use and disclosure of protected health information about you for treatment, payment or health care operations including disclosure to our business associates as noted above. You have the right to revoke this consent in writing, except where we have already made disclosures in reliance on you prior consent.
By submitting this form I consent to the use and disclosure of protected health information for treatment, payment or healthcare operations. |
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