NEW PATIENT REGISTRATION

Patient Information

Insurance Information

Emergency Contact Information

Authorized Personnel Only

Patient Consent FormI, the undersigned, hereby consent to the following treatment: • Administration and performance of all treatments. • Administration of any needed anesthetics. • Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient. • Use of prescribed medication. • Performance of diagnostic procedures, tests, and/or cultures. • Performance of other medically accepted laboratory test that may be considered medically necessary or advisable based on the judgment of the attending physician or their assigned designee. I fully understand that this is given in advance of any specific DIAGNOSIS, PROGNOSIS, MEDICATION, or treatment. I understand that I am fully responsible for any additional charges for laboratory testing not performed at Premier Urgent Care. I intend this consent to be continuing in nature even after a specific diagnosis or treatment. I understand that Premier Urgent Care may include consent at satellite offices under common ownership. I, the undersigned, acknowledge that Premier Urgent Care will use and disclose my information for the purposes of treatment, payment and healthcare options. A photocopy of this consent shall be considered as valid as the original.

MEDICARE PATIENTSI authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims; I assign the benefits payable for services to Premier Urgent Care. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Patient Receipt of HIPAA Privacy NoticeDear Patient, Premier Urgent Care is committed to maintaining the integrity of your protected health information and complies with all applicable state and federal regulations. The federal privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA) have taken effect April 14, 2003. In support of our policy of complying with all applicable regulations, Premier Urgent Care provides patients with the HIPAA Notice of Privacy Rights. While not required in order to receive treatment at Premier Urgent Care, we are obligated under federal regulations to ask that you sign an acknowledgment of the HIPAA Privacy Notice being made available to you. Thank you, Receipt of HIPAA Privacy Notice I acknowledge receipt of the Notice of Privacy Rights with detailed information about how Premier Urgent Care may use and disclose my protected health information. I understand that Premier Urgent Care reserves the right to change the privacy notice and that a copy of the revised notice will be made available to me.