CommunityMed Family Urgent Care | Open late and Weekends, boo-boos to broken bones, sniffles to stitches

Check In ID
Input Method
LocationID
Registration Unique ID
TO BE COMPLETED BY FRONT DESK
Alere Physicals Vendor Checkin
What is your closest or preferred clinic location*
Visit Type*
Select the reason you are coming in. If coming in for multiple reasons - select the most complex of the reasons. If your reason is not listed, select Medical Office Visit
This is a Corporate Remedies
- Yes, this visit is Corporate Remedies
Who is the patient?*
Is this physical for an employer already contracted with us, or is this a walk-in?
- Check here if Employer is NOT contracted and this is a walk-in employer physical or DOT physical
Does the patient have their eScreen form with barcode
- Yes
- No
Walk-in Employer Physical Clinic
Manual Form Selection
- Triage Form
- Car Accident
- Workplace Injury
- Drug Screen
- DOT Physical
- BAT Screen
- Release Authorization w/signature
- HIPPA with Permission to Treat w/signature
Front Desk Verified Driver's Identity by
Other method Identity is Confirmed
Has the PATIENT visited our clinic before?
- Patient is new, and has never been to a CommunityMed clinic
- Patient has been to a CommunityMed Clinic the past 12 months, and address, marital status, and insurance information has not changed
- Patient has been in the past 12 months, but some of the family information has changed (insurance, marital status, address, etc.)
- Patient is existing, but has not been to the clinic in the past 12 months
- Not sure
Checkin: https://forms.communitymedcare.com/

Patient Information
Patient Name
First Last
Patient Email
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
Optional - 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

Because the patient is a minor, they require an adult who is legally able to sign permission forms for the patient. The remaining information on this page is to be completed by this adult.
YOUR INFO AS THE GUARANTOR
(Adult Signing Form)
Your Name
First Last
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.
Your Primary Care Physician (optional)
If you want us to be able to send copies of visit paperwork to your primary care or pediatric physician

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
Insurance Policy Holder (Primary Insured)
- Patient does not have health insurance, They are self pay
- I am the insurance policy holder (the person primarily insured by the policy)
- Patient (not me) is the insurance policy holder (the person primarily insured by the policy)
- My spouse is the insurance policy holder (the person primarily insured by the policy)
- Someone besides myself or my spouse is the insurance policy holder (the person primarily insured by the policy)
Insurance Details
Policy Holder Name
First Last
Policy Holder Birthdate
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
Upload Your insurance card pictures
- I will upload to this form images of the front and back of my insurance cards
- I will TEXT images of the front and back of my insurance card to a secure text
If you are uploading or texting your insurance information, you do not need to fill the policy information in manually.
We will display texting instructions once you have completed this form, and also email you those instructions for texting us your photos of your insurance card
Upload FRONT of Your insurance card
Please take a clear close-up picture of the front of your insurance card. Please verify it is readable before uploading.
Upload for BACK of Your insurance card
Please take a clear close-up picture of the BACK of your insurance card. Please verify the small text including the phone and address of insurance company are readable before uploading.
Insurance Payer Name
Insurance Member Number
Insurance Group Number
Insurance Group Name
Insurance Payer Address
Found in small text on the back of the card
Insurance Payer Phone
found in small text on the back of the card

Enter your PERSONAL insurance details - this information will ONLY be used if Workers Comp denies your claim
SECONDARY/SUPPLEMENTAL Insurance
- Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy
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
Upload Your SECONDARY/SUPPLEMENTAL insurance card pictures
- I will upload to this form images of the front and back of my insurance cards
- I will TEXT images of the front and back of my insurance card to a secure text
If you are uploading or texting your insurance information, you do not need to fill the policy information in manually.
We will display texting instructions once you have completed this form, and also email you those instructions for texting us your photos of your insurance card
Upload Your SECONDARY/SUPPLEMENTAL FRONT of insurance card
Please take a clear close-up picture of the front of your insurance card. Please verify it is readable before uploading.
Upload Your SECONDARY/SUPPLEMENTAL BACK of insurance card
Please take a clear close-up picture of the BACK of your insurance card. Please verify the small text including the phone and address of insurance company are readable before uploading.
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

Workplace Injury Details
Date of the 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
Method for contact*
- I acknowledge that my email address will be used to contact me about information for this visit
- I acknowledge that my cellphone will be used to contact me 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 funds for the patient portion of the bill based on information available at the time of checkout. If additional information from the medical chart or insurance company processing change the required patient payment, CommunityMed will either credit the patient or bill the patient with the appropriate additional charges. The funds collected at checkout are estimated charges.
I understand that patients can check-in online before their visit and, even if they walk into the clinic after I did, they may be ahead of me in line because they registered hours before me. Additionally there may be a patient with a more severe injury or illness that may cause a delay to the time I scheduled online.
- Please email me a link to online check in so in the future I can do that too!

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
Guarantor Name
First Last
Patient Name
First Last
Patient Birthdate
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
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

Manual 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 2*
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 - Manual
Guarantor Name
First Last
Patient Name
First Last
Patient Birthdate
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 - Consent and HIPAA 2*
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

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
Email me a copy
- Please email me a copy of my paperwork
Patient GUID
Parent GUID
Guarantor GUID
Family GUID
Patient past due balance

TO BE COMPLETED BY FRONT DESK

PATIENT FORMS

DOT Physical Preliminary Questions

Minor Parent Info

Patient Information

YOUR INFO AS THE GUARANTOR

Workers Comp Insurance Details

Insurance Details

PRIMARY Insurance Policy Details

SECONDARY/SUPPLEMENTARY Insurance Policy Details

PLEASE HELP US!

For the Patient Visit Today:

Patient Drug Allergies

Medications Patient is Taking

Medical Problems

Patient Past Surgeries

Family Medical History

Share with us your Family Medical History

Additional Information

Car Accident Questions

Car Insurance Info

Workplace Injury Details

Acknowledgements

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

Manual Consent and Permission

Patient HIPAA Acknowledgment and Consent Form - Manual

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

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

TO BE COMPLETED BY FRONT DESK

PATIENT FORMS

DOT Physical Preliminary Questions

Minor Parent Info

Patient Information

YOUR INFO AS THE GUARANTOR

Workers Comp Insurance Details

Insurance Details

PRIMARY Insurance Policy Details

SECONDARY/SUPPLEMENTARY Insurance Policy Details

PLEASE HELP US!

For the Patient Visit Today:

Patient Drug Allergies

Medications Patient is Taking

Medical Problems

Patient Past Surgeries

Family Medical History

Share with us your Family Medical History

Additional Information

Car Accident Questions

Car Insurance Info

Workplace Injury Details

Acknowledgements

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

Manual Consent and Permission

Patient HIPAA Acknowledgment and Consent Form - Manual

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

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

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