CommunityMed Family Urgent Care
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Registration-

  • Registration Paperwork

  • You are checked in as in the parking lot


    BUT you MUST complete this Registration Paperwork to be seen. We have filled in a lot of it from your Online Check In


  • Used to determine which type of checkin (website, clockwise, telemed, etc.)
  • Date Format: MM slash DD slash YYYY
  • Alere Physicals  Vendor Checkin Manual Forms
  • 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


  • Select the type of visit you are coming for -
  • We need this to verify patient identity
  • 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.
  • Kept confidential - We use this for Identity confirmation & follow up communication.
  • This will be kept confidential, and only used internally to reach you for clinic reasons.
  • --
  • This is a calculated field to determine from answers to newvexisting, been last 12 mon, and no changes to info that the patient does not need to complete existing form info
  • DOT Physical Preliminary Questions

    We need an answer to a few simple questions to get you in the queue for a more comprehensive questionnaire
  • Additional Patient Information

  • This will be kept confidential, and only used internally to reach you for clinic reasons.
  • This will be kept confidential, and only used internally to reach you for clinic reasons.
  • Used for current record lookup only, we want to make sure we have the right person
  • Required - Used for current record lookup only, we want to make sure we have the right person
  • Put in cell number again if no home phone. This will be kept confidential, and only used internally to reach you for clinic reasons.
  • 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.
  • We need this to verify your identity
  • text version of parent DOB
  • current age, no decimal needed
  • This will be kept confidential, and only used internally to reach you for clinic reasons.
  • This will be kept confidential, and only used internally to reach you for clinic reasons.
  • YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)

    Continued from previous page
  • Used for current record lookup only
  • 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

  • Bring your insurance card into the clinic when you are called in for your visit.
  • Insurance Details

  • PRIMARY Insurance Policy Details

  • For example, Blue Cross or Aetna
  • please bring in your secondary insurance card as well
  • PLEASE HELP US!

    We’re trying to bring our convenient health care to other small communities, and it helps us to understand how our patients find us.
    Please help us by answering the following question; check all that apply
  • COVID Symptoms

  • PLEASE BE ADVISED

    Your insurance benefits MAY NOT cover the cost of the COVID visit and testing if you have not had recent, extended exposure and/or you do not have active symptoms.
  • Note from Visit

  • Car Accident Questions

    Necessary for us to properly diagnose the injury and file for reimbursement from insurance.
  • Car Insurance Info

    We will file the visit with valid motor vehicle insurance. Please provide the details below:
  • Workplace Injury Details

  • :
     
  • Hold CTRL to select multiple entries
  • 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.
  • 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:

  • Sign using mouse or or, on mobile, finger.
  • 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.
  • Date Format: MM slash DD slash YYYY
  • Patient HIPAA Acknowledgment and Consent Form

  • 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:

  • List names separated by commas
  • 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 **

  • List names separated by commas
  • Enter the authorized individuals relationships separated by commas
  • Sign using mouse or or, on mobile, finger.
  • 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.
  • Date Format: MM slash DD slash YYYY
  • Occ Med Registration

  • Sign using mouse or or, on mobile, finger.
  • 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.
  • 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