Patient Information Form - Amarillo Urgent Care

Patients Name

Sex

Male

Female

Home Phone

Cell Phone

Work Phone

Address

City

State

Zip Code

Date of birth (YYYY-MM-DD)

Social Security Number

Drivers License Number

Occupation

Employer

Employers Address

Primary Care Physician

Primary Care Physician Phone

Preferred Pharmacy

Preferred Pharmacy Phone

Emergency Notification

Name

Relationship

Address

City

State

Zip Code

Emergency Phone

Spouse Information

Name

Social Security Number

Date of birth (YYYY-MM-DD)

Employer (Company, City)

Spouse Phone

Insurance Information

Primary Plan

Address

City

State

Zip Code

ID Number

Group Name

Group Number

Co Pay Amount

Effective Date (YYYY-MM-DD)

Secondary Plan

Address

City

State

Zip Code

ID Number

Group Name

Group Number

Co Pay Amount

Effective Date (YYYY-MM-DD)

Guarantor/Insurance Policy Holder

Name

Address

City

State

Zip Code

Employer Name

Employer Address

City

State

Zip Code

Relationship to patient

General

Payment in full is due at time of visit. We will be happy to file your insurance for reimbursement, if we are participating with the plan. It is your responsibility to be aware of coverage limits on your insurance plan. If you have any questions regarding your insurance coverage of payment, you must contact the insurance company directly.

AUTHORIZATION FOR TREATMENT: I consent to examination, treatment, and any procedures including emergency treatment deemed necessary and ordered by our physicians and I am personally responsible for any charges.

AUTHORIZATION FOR INSURANCE: I authorize release of any information concerning myself or my child to my insurance company regarding treatment for services covered by my insurance plan.

AUTHORIZATION TO CONTACT ME: I hereby acknowledge that Amarillo Urgent Care may contact me, either by phone, email, or mail to provide a reminder of an appointment, gather demographic or insurance information, or to inform me of services or events offered at the facility.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE: I hereby acknowledge that Amarillo Urgent Care has provided me a copy of their Privacy Notice.

I understand that I am legally responsible for payment of all bills for care given by Amarillo Urgent Care to myself or any of my dependents, regardless of insurance reimbursement.

Patient or Responsible Party signature

Signature

Date (YYYY-MM-DD)