CommunityMed Family Urgent Care

Labid
Registration Paperwork
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Clinic-text
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regstate-in
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Car make and model
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schedule type
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Walkin visit time
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
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Check In ID
Used to determine which type of checkin (website, clockwise, telemed, etc.)
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browser
Registration Unique ID
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Visit Date
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 which clinic location you are visiting-*
We see you came from our scheduling system - What is DATE is your Scheduled Visit
Month
Day
Year
We see you came from our scheduling system - What TIME is your Schedule Visit
Visit Type-*
Select the type of visit you are coming for -
Is this COVID test for travel?
- Yes
- No
NOTE THAT YOU NEED TO VERIFY TEST REQUIREMENTS FOR YOUR TRAVEL DESTINATION
Different destinations require different types and sources of testing. Please look up and bring a copy of the test requirements for your destination to your visit.
What is the closest primary issue from this list for visit today?*
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Hospital ID

Patient Name-*
First Last
Patient Date of Birth-*
We need this to verify patient identity
Month
Day
Year
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Birthdate Text-
Has Patient ever been to ANY CommunityMed Clinic before?*
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Patient age-
current age, no decimal needed
Patient (or parent for minors) Email-*
Kept confidential - We use this for Identity confirmation & follow up communication.
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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.
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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
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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
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Patient Email
This will be kept confidential, and only used internally to reach you for clinic reasons.
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Patient Cell Phone
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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
Patient's Preferred Pharmacy?

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
Month
Day
Year
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Parent Date of Birth
text version of parent DOB
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Parent age
current age, no decimal needed
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Responsible Adult's Email
This will be kept confidential, and only used internally to reach you for clinic reasons.
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Responsible Adult's Cell Phone
This will be kept confidential, and only used internally to reach you for clinic reasons.
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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
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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

Payment for visit with - self pay or insured patient*
- Patient has health insurance
- Patient does not have health insurance. They are self-pay
NOTE: We do not accept Medicaid. We are not currently credentialed with any forms of Medicaid
Bring your insurance card into the clinic when you are called in for your visit.
Patient relationship to the Policy Holder*
Describe Other Policy Holder Relationship*
Insurance Details
Policy Holder Name
First Last
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Policy Holder Birthdate
Policy Holder Birthdate
Month
Day
Year
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Policy Holder Email
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Policy Holder Address - check if true
- Policy Holder (the person primarily insured) lives at the same address as me
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Policy Holder Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
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Policy Holder Home Phone
Policy Holder Cell Phone
PRIMARY Insurance Policy Details
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Primary Health Insurance Company Name
Health Insurance Company Name*
For example, Blue Cross or Aetna
PO Box on the back of the insurance card
Insurance Member Number
Insurance Group Number
Insurance Group Name

Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy
- Yes
- No
please bring in your secondary insurance card as well

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

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

:
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
Describe the circumstances around you getting this injury
Have you had a previous injury on these body parts?
- Yes
- No

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

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
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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
MM slash DD slash YYYY

Patient HIPAA Acknowledgment and Consent Form
Patient Name
First Last
Guarantor Name
First Last
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Patient Birthdate
Month
Day
Year
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
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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
MM slash DD slash YYYY

Occ Med Registration
Patient Name
First Last
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My Signature of Patient
Sign using mouse or or, on mobile, finger.
Employer
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
MM slash DD slash YYYY

You MUST CLICK the SUBMIT Button below to complete the forms and send your forms to the front desk,
or select PREVIOUS to edit/ change any form entry
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Patient past due balance

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

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

NOTE THAT YOU NEED TO VERIFY TEST REQUIREMENTS FOR YOUR TRAVEL DESTINATION

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

NOTE: We do not accept Medicaid. We are not currently credentialed with any forms of Medicaid

Insurance Details

PRIMARY Insurance Policy Details

PLEASE HELP US!

COVID Triage

PLEASE BE ADVISED

Note from Visit

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

You MUST CLICK the SUBMIT Button below to complete the forms and send your forms to the front desk,
or select PREVIOUS to edit/ 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 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

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

NOTE THAT YOU NEED TO VERIFY TEST REQUIREMENTS FOR YOUR TRAVEL DESTINATION

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

NOTE: We do not accept Medicaid. We are not currently credentialed with any forms of Medicaid

Insurance Details

PRIMARY Insurance Policy Details

PLEASE HELP US!

COVID Triage

PLEASE BE ADVISED

Note from Visit

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

You MUST CLICK the SUBMIT Button below to complete the forms and send your forms to the front desk,or select PREVIOUS to edit/ 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 MUST CLICK the SUBMIT Button below to complete the forms and send your forms to the front desk,
or select PREVIOUS to edit/ change any form entry