Registration Packet Please fill out the form, print it, and bring the form to your visit at Premier Urgent Care. Thank you and see you soon. Patient Packet Complete this Quick Registration Area if you have registered here before. If any information has changed since your last visit, please make changes below. Patient Name: Last Name DOB MM slash DD slash YYYY Are you above 18? Yes No Please enter your Guaranter's information.Name Relation Date of Birth MM slash DD slash YYYY Address Phone NumberEmergency ContactName Relation Date of Birth MM slash DD slash YYYY Address Phone Number NEW PATIENT REGISTRATION Are you here for a work related illness or injury? YES NO Where did you hear about Premier Urgent Care? Friend Mailer Newspaper Phone book Internet Radio Relative Physician Television Signage Work Other Pharmacy: Location: Patient Name: First Last M.I. MM slash DD slash YYYY Social Security Number:DOB: MM slash DD slash YYYY Address City State ZIP Home Phone:Cell Phone:Marital Status: Child Single Married Separated Divorced Widowed Gender: Male Female Race: Hispanic or Latino: Yes No Primary Care Physician: Date of Last Visit: Were you sent here from CENLA URGENT CARE? YES NO Email Address: A survey will be sent via email to rate your experience during today’s visit.Would you like your discharge papers emailed to you? YES NO Would you like access to our patient portal online? YES NO If you had not heard about us, where would you have most likely gone to be treated? Primary Care Doctor Emergency Room Another Urgent Care Not Been Seen Insurance Name: Policy # Are you the policy holder? YES NO If you are not the primary insurance holder please complete the following to ensure proper billing:Policy Holder Name: First Last DOB: MM slash DD slash YYYY SSN Address City State ZIP Home Phone:Cell Phone:AUTHORIZED PERSONNEL ONLYPrimary Insurance Verification Source: Secondary: Copay $Debt Collected: YES NO Amount Collected $Initial Was management contacted for any further authorization? YES NO Manager Name First Last 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 PATIENTS: I 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. Signature of Patient or Parent/Guardian Date MM slash DD slash YYYY 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.Signature of Patient or Parent/Guardian Date MM slash DD slash YYYY *****PRINTED OR ELECTRONIC COPIES OF HIPAA PRIVACY NOTICE ARE AVAILABLE UPON REQUEST*****Note: Please right click on any empty area on this page and select the print option to attain the hard copy. Premier Urgent Care accepts hard copy of this form.
