#_____ T:______

Established Patient Registration Patient Last Name ________________________________First Name _____________________________________ MI _____

Reason For Visit _______________________________________ Social Security Number _____________________________

D.O.B. ________________ Gender: ☐ M ☐ F Have you traveled outside the US in the last 21 days? ☐ Yes ☐ No

Email Address ____________________________________________________Phone #_________________________________

Pharmacy Name _________________________________Pharmacy Location______________________________________

Has your address changed since your last visit? ☐ Yes ☐ No Has your insurance changed since your last visit? ☐ Yes ☐ No *If yes to either question above, please stop here and see the receptionist

Insurance co-pay amount $ __________________________ OR Self Pay ☐ If you do not know your co-pay amount and it is not printed on your card, or you have a percentage plan co- pay, you will be charged a $30 fee to be seen. If your co-pay is determined to be less than $30 after your visit, you will be eligible for a refund from our billing company.

Medical Information Release Form (HIPAA Release Form) I authorize the release of information from this visit including the diagnosis, records, examination rendered to me, and claims information. This information may be released to (please print): ☐ Name of Spouse:________________________________________________________________________________________

☐ Name of Employer: ____________________________________________________________________________________

☐ Name of Other: _________________________________________________________________________________________

Would you like your primary care provider to have access to these records? Yes ☐ No ☐

☐ Information is not to be released to anyone.

This Release of Information will remain in effect for this visit to the listed individuals until terminated by me in writing. _____________________________________________________________________________________________________ Patient/Guardian Signature I consent to all treatment from this clinic deemed necessary by the treating provider, and I agree to cover the financial cost of this treatment. On my first visit to this clinic, I read and signed the patient financial responsibility agreement, and I understand that this agreement is in effect for all subsequent visits. Patient/Guardian Signature ______________________________________________________ Date_________________

Patient Financial Responsibility Form

Thank you for choosing It’s About Time Urgent Care for your medical needs. We are committed to providing you with the

highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial

policies. This agreement is in effect for this and all future visits to It’s About Time Urgent Care.

Patient Financial Responsibilities • The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment for treatment & care.

• We will bill your insurance for you. However, the patient is required to provide

the most correct and updated information regarding insurance.

• Patients are responsible for payment of copays, coinsurance, deductibles and all other procedures or

treatment not covered by their insurance plan.

• Copays are due at the time of service.

• Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing.

• Patients may incur, and are responsible for payment of additional charges, if applicable. These charges

may include a $30.00 charge for returned checks.

• Accounts placed with a third party collection agency will be subject to a collection cost of 33.33%

You may become responsible for the medical costs of treatment for your illness or condition with the provider listed below if (1) you fail to pursue the claim for workers’ compensation or (2) it is determined by the Workers’ Compensation Board that the

illness or condition which required treatment was not a result of a compensable workplace accident or occupational disease or

(3) if an agreement is executed by you and approved pursuant to Workers’ Compensation Law §32 in which you waive your right

to medical benefits from the workers’ compensation carrier/self-insured employer for treatment/ services performed after the

date the agreement is approved. If any of the above events occurs, the provider may bill you directly instead of the employer or

insurance carrier, and you will be responsible for the provider’s fees for services rendered.

You expressly consent and agree that, in order to discuss or service your accounts(s) (the “Accounts “) or to collect amounts you

may owe, It’s About Time Urgent Care and its officers, agents, affiliates, employees, and any affiliated or associated service

providers and any third-party debt collection agency associated therewith (collectively, “We”) may contact you by telephone at

any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you.

You expressly consent and agree that We may also contact you by sending text messages, emails, using any e-mail address you

provide to us, or by pre-recorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and pre-

recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile

telephone numbers, regardless of whether you incur charges as a result.

By my signature below, I hereby authorize assignment of financial benefits directly to It’s About Time Urgent Care and any

associated healthcare entities for services rendered as allowable under standard third party contracts. I understand that I am financially responsible for charges not covered by this assignment.

Patient Name ___________________________________________________________Date__________________________________ Patient/Guardian Signature______________________________________________________________________________________

 

 

 

Credit Card/ Debit Card Authorization

It’s About Time Urgent Care submits claims to insurance carriers as a

convenience to all our patients. At this time we request authorization to bill a

major credit card or debit card to cover amounts determined by your insurance

to be your responsibility.

Upon receipt of an explanation of benefits from your insurance carrier, any

unpaid portion of your claim will be billed to your credit card or debit card.

Should insurance pay in full, your account will not be charged. The maximum

amount that your credit card could be charged for this visit is $300.00. This

authorization will not put a hold on your credit or debit card.

All credit card/debit card information will remain absolutely confidential and

securely stored by First Data for 90 days. It’s About Time Urgent Care will not

store any banking account data.

I hereby authorize It’s About Time Urgent Care to charge any and all outstanding balances, after insurance company reimbursement or denial, to my credit/debit card. I understand that I will not receive a statement if there is no balance due after processing my credit card for payment.

_________________________________________________ ______________________ Cardholder’s Authorization Signature Date _____________________________________________________________________________Email Address (required) You will be notified by email 7 days in advance of your credit card being charged, and given contact information for the billing company to make other arrangements if needed.