CommunityMed Family Urgent Care |

Check In ID
Used to determine which type of checkin (website, clockwise, telemed, etc.)
browser
Registration Unique ID
Visit Date
Date Format: MM slash DD slash YYYY
Alere Physicals Vendor Checkin Manual Forms
Telemed Registration - Step 2
Telemed is offered by appointment.
Step 1) Book your desired appointment time,
Step 2) Complete your registration forms and pay
Step 3) Upload your ID
We will then text you the link to join your telemed visit at your appointed time
Your visit time is reserved, and you will receive a text and email of your reserved visit time
BUT YOUR VISIT IS NOT CONFIRMED UNTIL YOU COMPLETE THIS REGISTRATION PAPERWORK
What is your closest or preferred clinic location-*
Visit Type-*
Select the type of visit you are coming for - FOR COVID TESTING SELECT URGENT CARE VISIT. unsure? select Urgent Care Visit

Patient Name-*
First Last
Patient Date of Birth-*
We need this to verify patient identity
MM
DD
YYYY
Birthdate Text-
Has Patient ever been to ANY CommunityMed Clinic before?*
Patient age-
current age, no decimal needed
Unfortunately, because of the complexity of diagnosing, treating, and prescribing for younger children, we are unable to take children over telemedicine
Select your closest clinic below and complete this paperwork, and we will get you into your closest clinic. Our virtual waiting room allows you to wait in your car and be taken straight back.
Patient (or parent for minors) Email-*
Kept confidential - We use this for Identity confirmation & follow up communication.
email as text
Patient (or parent for minors) Cell Phone-*
This will be kept confidential, and only used internally to reach you for clinic reasons.
Patient (or Parent for minors) Cell Phone-

Employer
This is a Corporate Remedies covered employer visit
- Yes, this visit is Corporate Remedies
Is this occupational medicine or work injury visit for an employer already contracted with us, or is this a walk-in?
- Employer is already contracted with CommunityMed
- Patient is a walk-in occ med or workplace injury
- Unsure
Does the patient have their eScreen form with barcode
- Yes
- No
Walk-in Employer Physical Clinic
Verification of Driver's Identity by
Other method Identity is Confirmed

DOT Physical Preliminary Questions
We need an answer to a few simple questions to get you in the queue for a more comprehensive questionnaire
Is this an existing commercial driver's license
- YES
- NO, this is a Commercial learners Permit
Reason for New DOT Physical*
Driver's License State*
Commercial Driver's License Number*
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?
- Yes
- No
- Not Sure

Additional Patient Information
The information below is for Patient Named
First Last
Patient Email
This will be kept confidential, and only used internally to reach you for clinic reasons.
Patient Cell Phone
Patient Cell Phone
This will be kept confidential, and only used internally to reach you for clinic reasons.
Last 4 digits of patient social security*
Used for current record lookup only, we want to make sure we have the right person
Patient social security*
Required - Used for current record lookup only, we want to make sure we have the right person
Patient Sex
- M
- F
Patient Marital Status
- Single
- Married
- N/A

Patient Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell is home phone
- We have no home landline - Cell is home phone
Patient Home Phone
Put in cell number again if no home phone. This will be kept confidential, and only used internally to reach you for clinic reasons.
Patient Primary Care Physician (optional)
If you want us to be able to send copies of visit paperwork to their primary care or pediatric physician

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)
Because the patient is a minor, they require an adult who is legally able to sign permission forms for the patient (usually the parent or guardian). The remaining information on this page is to be completed by this adult. The guarantor is the Adult, responsible for the Minor, who is signing the form.
Parent Name (Guarantor)
First Last
Parent Date of Birth*
We need this to verify your identity
MM
DD
YYYY
Parent Date of Birth
text version of parent DOB
Parent age
current age, no decimal needed
Responsible Adult's Email
This will be kept confidential, and only used internally to reach you for clinic reasons.
Responsible Adult's Cell Phone
This will be kept confidential, and only used internally to reach you for clinic reasons.
Responsible Adult cell number
Your Relationship to Patient
- Parent/Step Parent
- Spouse

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)
Continued from previous page
Last 4 digits of Your social security*
Used for current record lookup only
Your Sex
- M
- F
Your Legal Marital Status
- Single
- Married
Guarantor Address
- Check here if Patient lives at same address as me
Your Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Home Phone
If no home phone, repeat cell number for both. This will be kept confidential, and only used internally to reach you for clinic reasons.

Workers Comp Insurance Details
Legal Name of Company from Authorization Form
Workers Comp Insurance Company Name
Workers Comp Insurance Billing Address
Street Address Address Line 2 City State ZIP Code
Workers Comp Insurance Phone

Enter your PERSONAL insurance details - this information will ONLY be used if Workers Comp denies your claim
Payment for visit with as self pay or insured patient*
- Patient has health insurance
- Patient does not have health insurance. They are self-pay
Patient relationship to the Policy Holder*
Describe Other Policy Holder Relationship*
Insurance Details
Pull Information from Parent Guarantor
- Populate the information in this section from The Parent (Guarantor) section previously completed
You can still change specific information below if necessary
Policy Holder Name
First Last
Policy Holder Birthdate
Policy Holder Birthdate
MM
DD
YYYY
Policy Holder Email
Policy Holder Address - check if true
- Policy Holder (the person primarily insured) lives at the same address as me
Policy Holder Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Policy Holder Home Phone
Policy Holder Cell Phone

Enter your PERSONAL insurance details - this information will ONLY be used if Workers Comp denies your claim
PRIMARY Insurance Policy Details
Primary Health Insurance Company Name
Health Insurance Company Name*
For example, Blue Cross or Aetna
Insurance Payer Address*
Found in small text on the back of the card. Usually a PO BOX
Insurance Company Phone*
found in small text on the back of the card
Insurance Member Number*
Insurance Group Number*
Insurance Group Name

Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy
- Yes
- No
Secondary Insurance Policy Holder (the person named as primary on the insurance)
- You are the primary insured on the secondary/supplemental policy
- The Patient (not me) is the primary insured on the secondary/supplemental policy
- Your spouse is the primary insured on the secondary/supplemental policy
- A different person (besides myself or my spouse) is the primary insured on my secondary/supplemental insurance
Secondary/supplementary Policy Holder Name
First Last
Secondary/supplementary Policy Holder Sex
- M
- F

SECONDARY/SUPPLEMENTARY Insurance Policy Details
Secondary/supplementary Policy Holder Home Phone
Secondary/supplementary Policy Holder Cell Phone
Secondary/supplementary Insurance Payer Name
Secondary/supplementary Insurance Member Number
Secondary/supplementary Insurance Group Number
Secondary/supplementary Insurance Group Name
Secondary/supplementary Insurance Payer Phone
found in small text on the back of the card

I will possibly need a Clinic note from this visit (to include test results)
- Yes
- No
Note from Visit
Type of Note you need
Describe Other
School District
School Note Customer Verbiage -ISD

Patient Drug Allergies
Is patient allergic to any prescription or over-the-counter medications(s)?*
- Yes
- No
Medical Allergies Since Last Visit
- Check Here if patient Medical Allergies are UNCHANGED since your last visit
Medication Allergy 1*
Medication Allergy 1 hidden
Enter Other Medication Allergy 1*
Medication Allergy 2
Medication Allergy 2 hidden
Enter Other Medication Allergy 2*
Medication Allergy 3
Medication Allergy 3 hidden
Enter Other Medication Allergy 3*
Medication Allergy 4
Medication Allergy 4 hidden
Enter Other Medication Allergy 4*
Medication Allergy 5
Medication Allergy 5 hidden
Enter Other Medication Allergy 5*
Medication Allergy 6
Medication Allergy 6 hidden
Enter Other Medication Allergy 6*
Medication Allergy 7
Medication Allergy 7 hidden
Enter Other Medication Allergy 7*
Medication Allergy 8
Medication Allergy 8 hidden
Enter Other Medication Allergy 8*
YOU MUST ADD A MEDICATION ABOVE OR SELECT THAT PATIENT HAS NO MEDICATION ALLERGIES

Medications Patient is Taking
Is patient currently taking prescription or over-the-counter medications(s)?*
(If you have a current written list, the front desk can enter it for you)
- Yes
- No
Patient Medications Since Last Visit
- Check Here if patient medications and dosages are UNCHANGED since your last visit
Medication 1*
Medication 1 hidden
Enter Other Medication 1*
Medication 2
Medication 2 hidden
Enter Other Medication 2*
Medication 3
Medication 3 hidden
Enter Other Medication 3*
Medication 4
Medication 4 hidden
Enter Other Medication 4*
Medication 5
Medication 5 hidden
Enter Other Medication 5*
Medication 6
Medication 6 hidden
Enter Other Medication 6*
Medication 7
Medication 7 hidden
Enter Other Medication 7*
Medication 8
Medication 8 hidden
Enter Other Medication 8*

Medical Problems
Does patient have any significant current or ongoing medical problems?*
- Yes
- No
Patient Medical Problems Since Last Visit
- Check Here if patient medical problems UNCHANGED since your last visit
Medical Problem 1*
Medical Problem 1 hidden
Enter Other Medical Problem 1*
Medical Problem 2
Medical Problem 2 hidden
Enter Other Medical Problem 2*
Medical Problem 3
Medical Problem 3 hidden
Enter Other Medical Problem 3*
Medical Problem 4
Medical Problem 4 hidden
Enter Other Medical Problem 4*
Medical Problem 5
Medical Problem 5 hidden
Enter Other Medical Problem 5*
Medical Problem 6
Medical Problem 6 hidden
Enter Other Medical Problem 6*
Medical Problem 7
Medical Problem 7 hidden
Enter Other Medical Problem 7*
Medical Problem 8
Medical Problem 8 hidden
Enter Other Medical Problem 8*

Patient Past Surgeries
Has patient previously had any significant surgeries?*
- Yes
- No
Patient Surgeries Since Last Visit
- Check Here if patient past surgeries are UNCHANGED since your last visit
Past Surgery 1*
Past Surgery 1 hidden
Enter Other Past Surgery 1*
Past Surgery 2
Past Surgery 2 hidden
Enter Other Past Surgery 2*
Past Surgery 3
Past Surgery 3 hidden
Enter Other Past Surgery 3*
Past Surgery 4
Past Surgery 4 hidden
Enter Other Past Surgery 4*

Additional Information
Patient's Last Menstrual Period?
Does the patient smoke or vape?*
- yes
- no
Number of times/day?
Does the patient Drink Alcohol?*
- Never
- Socially
- Heavily
Patient Immunization Status*
- Up to date
- Not up to date
- Does not vaccinate
- Unsure
List any recent (past 3 months) international travel destinations
Patient's Preferred Pharmacy?
Patient's Primary Physician?

What to expect when you visit CommunityMed Urgent Care for your COVID testing sponsored by Collin County

Included in this sponsored visit, at no charge to you:
- You will have your vital signs measured
- You will be seen by a medical professional
- You will get the Oral swab test done looking for active COVID infection
- If you have fever or other symptoms, you may also get
- Strep and flu test at no additional cost
Collin county will not pay for:
- Medications
- Breathing treatments
- X-rays
- COVID blood testing
- Any testing or treatments not listed above
If you need any additional testing or treatments based on your presentation and symptoms,
a practitioner will discuss the medical reasons for these additional items and you will be given
the option to pay for these at the time of the visit at a reduced cash pay price.
Patient Initials acknowledging what to expect for Collin County Uninsured visit*

Car Insurance Info
We will file the visit with valid motor vehicle insurance. Please provide the details below:
Auto Policy Number
Accident Claim Number
Date of injury
Insurance Company Name
Insurance Company Phone Number
Insurance Adjuster's Name
First Last
Insurance Adjuster Phone Number
Insurance Adjuster Email Address (If known)

Workplace Injury Details
Date of Injury
Approximate Time of the injury

HH :

MM
Did you report the injury to your employer?
- Yes
- No
To who at your employer (person's name) did you report the injury?
Date you reported it
What is your injury?
Select the part(s) of your body injured
Hold CTRL to select multiple entries
Have you had a previous injury on these body parts?
- Yes
- No
Describe the circumstances around you getting this injury

Acknowledgements
Please acknowledge the following information and permissions. Note that in these difficult time and for safety and convenience of patients, we require acceptance of practice interaction with patients through email, voicemail, and text in order for you to be a patient. This includes personal and health information to the patient and referring medical practices.
Method for contact*
- I acknowledge and authorize that my email address will be used to contact me and referring physicians about information for this visit
- I acknowledge and authorize that my cellphone voice and voicemail will be used to contact me and referring physicians about information for this visit
- I acknowledge and authorize that my cellphone text will be used to contact me and referring physicians about information for this visit
Additional Permissions for contact
- I give additional permissions for ONLY COMMUNITYMED to send me occasional email about specials, health information, and new clinic offerings
- I give additional permissions for ONLY COMMUNITYMED to send me occasional texts about specials, health information, and new clinic offerings
Our Patient Billing*
- I understand that CommunityMed will collect an ESTIMATE of the patient portion of the bill. The funds collected at checkout are estimated charges, and I may owe more after the medical chart is completed and insurance processes.

Application for Collin County COVID-19 Testing Application
Check YES below if Patient or Guardian (for Minor patients) is a Collin County Resident, does not have private or public health insurance (i.e. Blue Cross, United Healthcare, Medicaid, Medicare, etc.), and wants to submit an application for Collin County to pay for COVID-19 PCR Testing
- YES
Collin County Health Care Services 2019 Novel Coronavirus (COVID-19) Testing Application
(Patient Initials) certifying the following:*
I hereby certify, under penalty of perjury, my (or my child’s) status as a medically uninsured
resident of Collin County: I affirm that I (or my child) currently reside(s) in Collin County. I affirm that I am not (or my
child is not) presently covered by any public or private health insurance program (i.e. Blue Cross, United Healthcare,
Medicaid, Medicare, etc.).

I understand Collin County Health Care Services has authorized my chosen health care provider to perform certain
COVID-19 related services for me (or my child) free of charge based on the information I have provided on this form.
By signing this form, I agree the statements I have made, including my answers to all questions, are true and correct to the best
of my knowledge and belief. I understand that giving false information could result in disqualification from and a requirement
to repay for COVID-19 services.

Consequence of Fraud Policy: If, after due process, a person is found to have intentionally misrepresented information in
order to receive COVID-19 services, that person:
- shall reimburse Collin County for the cost of benefits they were ineligible to receive;
- shall be administratively ineligible for Collin County COVID-19 services in accordance with County Policies/Procedures;
- shall be financially responsible for any insurance or other billing generated by their chosen health care provider as allowable for services received; and
- may be subject to prosecution under Texas Penal Code.
I understand that as part of the provisions of healthcare services, Collin County creates and maintains health records and other
information describing, among other things, my health and medical history, symptoms, examination and test results, diagnoses,
treatment, and any plans for future care of treatment.
Type Name of person completing application*
First Last
Signature of Person Completing Application*
Relationship to patient*
Date*
Date Format: MM slash DD slash YYYY

Consent and Permission
I authorize the release of information necessary to process this claim and assign benefits payable for services directly to CommunityMed PCP, PLLC or CommunityMed PLLC, herein referred to as CommunityMed Urgent Care. I authorize the release of any medical information necessary for treatment by my current or future physician or health care provider. I authorize CommunityMed Urgent Care to release to my insurance company any medical information that may be necessary to process my insurance claim. CommunityMed Urgent Care is an urgent care facility. At the time of your visit payments will be collected based on your Urgent Care benefits and your insurance carrier will be billed. I understand that in the event my insurance company denies this claim, I will be held financially responsible for all charges, including any collection fees, court costs and all attorneys’ fees incurred by CommunityMed Urgent Care in collecting a delinquent account.
I am the Guarantor (Person financially responsible for any balance not paid by insurance). I am also a legal guardian for these minors and able to sign medical permissions on their behalf.
The following are minors that this applies to:
Patient Name
First Last
Guarantor Signing these forms
First Last
Signature of Guarantor*
Sign using mouse or or, on mobile, finger.
Type Name for Electronic Signature - Consent and Permission*
Typing your name here is an acknowledgement that you accept electronic signatures as legally binding, and your typing of your name here is your electronic signature.
Signature Date
Date Format: MM slash DD slash YYYY

Patient HIPAA Acknowledgment and Consent Form
Patient Name
First Last
Guarantor Name
First Last
Patient Birthdate
MM
DD
YYYY
Healthcare information may be released to any person or entity liable for payment on the Patient’s behalf to verify coverage or payment questions, or for any other purpose related to benefit payment. I hereby permit this practice and the health professionals involved in my care to release healthcare information for purposes of treatment, payment, or healthcare operations. As provided by Privacy Rule Section 164.522(b), I hereby allow the Practice to communicate via phone, email, postal mail and text to the address, email address and phone numbers provided on my intake form.

Consent to Treatment: I understand that a medical practitioner at my request will order all test and treatment at CommunityMed Urgent Care. I understand that medicine is not an exact science and that there is no guarantee that the outcome of my treatment will be what I want it to be. Knowing this, and agreeing to this, I request to be a patient at CommunityMed Urgent Care. I consent to all necessary testing and treatment, including procedures and routine immunizations, while I am a patient at CommunityMed Urgent Care on this date through a full calendar year from this date. If this paperwork is being completed for my minor child I consent to all necessary testing and treatment while he / she is a patient at CommunityMed Urgent Care on this date through a full calendar year from this date. I consent to photographs being taken for the purpose of medical treatment and diagnosis. I authorize CommunityMed Urgent Care to retain for testing and/or dispose of any specimen or tissue taken from the above-named patient.

Notice of Privacy Practices: I acknowledge that I have reviewed the clinic’s posted Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

Accidental Exposure of Healthcare Workers: I understand that state law provides for, and I agree, that if any healthcare worker is exposed to my blood or other bodily fluids to allow CommunityMed Urgent Care to perform tests on my blood or other bodily fluids to determine the presence of any communicable diseases, including but not limited to, hepatitis, human immunodeficiency virus (AIDS), and syphilis. I understand that such testing is necessary to protect those who will be caring for me while I am a patient at CommunityMed Urgent Care. I understand that the results of test taken under these circumstances do not become part of my medical record.
THE FOLLOWING INDIVIDUALS MAY ACCESS THIS PATIENTS HEALTH INFORMATION AND REQUEST RECORDS ON THE PATIENT'S BEHALF:
Authorized Individuals
List names separated by commas
Authorized Individual Relationships
Enter the authorized individuals relationships separated by commas
THE FOLLOWING INDIVIDUALS MAY AUTHORIZE MEDICAL TREATMENT ON BEHALF OF MY MINOR CHILD: ** TO BE COMPLETED ONLY IF PATIENT IS A MINOR CHILD **
Individuals Authorized to Approve Minor Medical Care
List names separated by commas
Relationship of Authorized Individual(s) to the Patient
Enter the authorized individuals relationships separated by commas
Name of Authorized Signer
First Last
My Signature as Authorized Adult and Legal Guardian*
Sign using mouse or or, on mobile, finger.
Type Name for Electronic Signature - HIPAA and Consent
Typing your name here is an acknowledgement that you accept electronic signatures as legally binding, and your typing of your name here is your electronic signature.
Signature Date
Date Format: MM slash DD slash YYYY

Occ Med Registration
Patient Name
First Last
Employer
My Signature of Patient*
Sign using mouse or or, on mobile, finger.
Type Name for Electronic Signature - Occ Med Registration*
Typing your name here is an acknowledgement that you accept electronic signatures as legally binding, and your typing of your name here is your electronic signature.
Signature Date
Date Format: MM slash DD slash YYYY

Email me a copy
- Please email me a copy of my paperwork
You have completed the forms,
select the SUBMIT button below to send your forms to the front desk,
or select PREVIOUS to change any form entry
Patient past due balance

Registration-

Telemed Registration - Step 2

BUT YOUR VISIT IS NOT CONFIRMED UNTIL YOU COMPLETE THIS REGISTRATION PAPERWORK

DOT Physical Preliminary Questions

Additional Patient Information

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)

Workers Comp Insurance Details

Insurance Details

PRIMARY Insurance Policy Details

SECONDARY/SUPPLEMENTARY Insurance Policy Details

PLEASE HELP US!

SPECIFICS For the Patient Visit TODAY:

Note from Visit

Patient Drug Allergies

Medications Patient is Taking

Medical Problems

Patient Past Surgeries

Family Medical History

Share with us your Family Medical History

Additional Information

What to expect when you visit CommunityMed Urgent Care for your COVID testing sponsored by Collin County

Car Accident Questions

Car Insurance Info

Workplace Injury Details

Acknowledgements

Collin County Health Care Services 2019 Novel Coronavirus (COVID-19) Testing Application

Consent and Permission

Patient HIPAA Acknowledgment and Consent Form

THE FOLLOWING INDIVIDUALS MAY AUTHORIZE MEDICAL TREATMENT ON BEHALF OF MY MINOR CHILD: TO BE COMPLETED ONLY IF PATIENT IS A MINOR CHILD

Occ Med Registration

You have completed the forms,
select the SUBMIT button below to send your forms to the front desk,
or select PREVIOUS to change any form entry

Head
Face
Neck
Left Shoulder
Right Shoulder
Upper Chest
Upper Back
Left arm
Left Hand/Fingers
Right arm
Right Hand/Fingers
Left ribs
Right ribs
Stomach
Back
Hips
Lower back
Butt
Left Thigh
Right Thigh
Left knee
Right Knee
Left shin
Right Shin
Left ankle
Right ankle
Left foot/toes
Right Foot/toes

Registration-

Telemed Registration - Step 2

BUT YOUR VISIT IS NOT CONFIRMED UNTIL YOU COMPLETE THIS REGISTRATION PAPERWORK

DOT Physical Preliminary Questions

Additional Patient Information

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)

Workers Comp Insurance Details

Insurance Details

PRIMARY Insurance Policy Details

SECONDARY/SUPPLEMENTARY Insurance Policy Details

PLEASE HELP US!

SPECIFICS For the Patient Visit TODAY:

Note from Visit

Patient Drug Allergies

Medications Patient is Taking

Medical Problems

Patient Past Surgeries

Family Medical History

Share with us your Family Medical History

Additional Information

What to expect when you visit CommunityMed Urgent Care for your COVID testing sponsored by Collin County

Car Accident Questions

Car Insurance Info

Workplace Injury Details

Acknowledgements

Collin County Health Care Services 2019 Novel Coronavirus (COVID-19) Testing Application

Consent and Permission

Patient HIPAA Acknowledgment and Consent Form

THE FOLLOWING INDIVIDUALS MAY AUTHORIZE MEDICAL TREATMENT ON BEHALF OF MY MINOR CHILD: ** TO BE COMPLETED ONLY IF PATIENT IS A MINOR CHILD **

Occ Med Registration

You have completed the forms, select the SUBMIT button below to send your forms to the front desk,or select PREVIOUS to change any form entry

THE FOLLOWING INDIVIDUALS MAY AUTHORIZE MEDICAL TREATMENT ON BEHALF OF MY MINOR CHILD: TO BE COMPLETED ONLY IF PATIENT IS A MINOR CHILD

You have completed the forms,
select the SUBMIT button below to send your forms to the front desk,
or select PREVIOUS to change any form entry