Registration Packet – Premier Urgent Care

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:

DOB

Are you above 18?

Yes
No

Please enter your Guaranter's information.

Name

Relation

Date of Birth

Address

Phone Number

Emergency Contact

Name

Relation

Date of Birth

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?

Pharmacy:

Location:

Patient Name:

First Last

M.I.

Social Security Number:

DOB:

Address City State ZIP

Home Phone:

Cell Phone:

Marital Status:

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:

SSN

Address City State ZIP

Home Phone:

Cell Phone:

AUTHORIZED PERSONNEL ONLY

Primary 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 FORM

I, the undersigned, hereby consent to the following treatment:

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

PATIENT RECEIPT OF HIPAA PRIVACY NOTICE

Dear 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

*****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.

Patient Packet

AUTHORIZED PERSONNEL ONLY