PATIENT REGISTRATION FORM
Fields identified with an (*) must be completed.
Today’s Date: ___________________
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Patient Name (First, Middle, Last)*: _________________________________________ Date of Birth*: ____ /____ /____
SSN: _____-___-______ Gender: m Male m Female Marital Status: m Single m Married m Divorced m Widowed
Primary Care/Provider (PCP) Name: _____________________________ PCP Phone: ____________________________
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Mailing Address*: _________________________________________ City*: _____________ State*: ____ Zip*: ________
Contact Numbers: Main* ______________________ Mobile _____________________ Work ____________________
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Please provide your EMAIL ADDRESS ___________________________________________ so that we can let you know about any
insurance carrier changes, health alerts, changes in clinic hours, new locations, FastMed services and other important issues. Email address will not be provided to a third party.
Emergency Contact: ____________________________________ Emergency Contact Phone: _____________________
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ETHNICITY/RACE:
m African-American m American Indian/Alaska Native m Asian m Caucasian m Hispanic
m Paciic Islander/Hawaiian m Decline Response Preferred Language: ________________________________________
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HOW DID YOU HEAR ABOUT FASTMED? Check ALL that apply.
m Healthcare provider referral m Friend/ family m Print advertising |
m Mailer m Employer m Event |
m TV |
m Online (FastMed.com, Yelp, Web search, online advertisement, social media) |
m Other: Please list ______________________ |
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INSURANCE INFORMATION:
Insurance Subscriber’s Name (First, Middle, Last): ____________________________________ Relation: _____________
Date of Birth: ___ /___ /______ SSN: _____-___-______ Employer: __________________________________________
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RESPONSIBLE PARTY:
COMPLETE FOR MINOR PATIENTS OR WHEN PATIENT IS NOT FINANCIALLY RESPONSIBLE FOR THE ACCOUNT Name of Person Responsible for this Account: ____________________________________________________________
Relation: ______________ Date of Birth: ___ /___ /______ SSN: _____-___-______ Phone: _______________________
Mailing Address: _________________________________________ City: ________________ State: ____ Zip: ________
Primary Insurance: __________________________________ Secondary Insurance: ______________________________
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WORKERS’ COMPENSATION (“WC”) AUTHORIZATION:
Employer Name : _____________________________________________________ Phone: ________________________
Address: ______________________________________ City: ___________________ State: ________ Zip: ____________
WC Carrier: ___________________________ Phone: ___________________ Claim #: ____________________________
Address: ______________________________________ City: ___________________ State: ________ Zip: ____________
Date of Injury: ____________ Employer Contact: ______________________ Injury Reported to Employer: YES NO
I clearly understand and agree that all services rendered to me will be charged directly to me in the event that Workers’ Compensation Beneits are denied.
Patient Signature: __________________________________________________________ Date: ____________________
FINANCIAL POLICIES:
Payment is required for all services at the time they are rendered, unless you are in a prepaid insurance plan in which we participate. Applicable co-payment and deductibles will be collected at the time of service. I understand that I am inancially responsible for all services rendered that are not paid for by my insurance(s). I understand that a $10 late fee will be applied to any unpaid patient balance not paid within 30 days. Additionally, the actual charges that we are required to pay for collection services by our third party collection services will be added to your account if your account goes into collections after
60 days of non-payment. The collection fee can be up to an additional 40% of the unpaid bill. I authorize the release of information concerning my (or my child’s) healthcare, advisement, and treatment provided for the purpose of evaluation and administering claims for insurance beneits. All medical services will be billed by FastMed Urgent Care. I also authorize payment for insurance beneits, otherwise payable to me directly, to FastMed Urgent Care.
Patient/Patient Representative Signature: ______________________________________________ Date: ____________
To ensure all inancial obligations are met in a timely manner, FastMed’s PayWell service is used to apply payment card information to authorize a maximum payment of $200 towards any unpaid balances after the services have been billed to the insurance provided at the time of service. If there are any unpaid balances, you will receive an email (if provided) three days prior to your payment card being charged indicating the amount that will be charged. I authorize the payment card being presented today to be used by FastMed Urgent Care to cover any unpaid balances (for today’s service only) following submission of claims to my insurance plan.
Patient/Patient Representative Signature: ______________________________________________ Date: ____________
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ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES*:
I have read and had questions addressed concerning FastMed Urgent Care’s Notice of Privacy Practices.
m I give my permission to have messages concerning my care left on my voicemail. Preferred number: ________________
m I do NOT give my permission to have messages concerning my care left on my voicemail.
Patient/Patient Representative Signature: ______________________________________________ Date: ____________
For Oice Use Only
A good faith efort was made in attempting to obtain written acknowledgement of receipt of the FastMed Urgent Care Notice of Privacy Practices. Acknowledgement could not be secured for the following reasons:
m Patient/representative refused to sign. Date of Refusal: ________________
m Communication barriers prohibiting obtaining an acknowledgement
m An emergency situation prevented us from obtaining an acknowledgement
m Other. Please explain: _____________________________________________________________________________
Staf Signature: _______________________________________________
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ACKNOWLEDGEMENT OF PATIENT CHOICE POLICY*:
In connection with your treatment at FastMed Urgent Care, your FastMed Urgent Care healthcare provider may recommend certain ancillary services as part of your overall care. FastMed Urgent Care ofers certain ancillary services that patients may require such as x-rays, limited lab services and certain pharmaceuticals. FastMed has arranged for limited durable equipment (DME) to be available on-site for patient convenience through a third party vendor. While FastMed Urgent Care makes these services available, we want you to know that if your FastMed Urgent Care healthcare provider prescribes any of these services for you, you are free to choose any provider or supplier you wish and are not required to obtain these services through or at FastMed Urgent Care. FastMed Urgent Care will ofer local providers of such items and services to you upon your request.
I have been given the opportunity to review the forgoing regarding FastMed Urgent Care’s Patient Choice Policy and have had any questions answered about the same addressed. By signing below, I acknowledge my understanding of this policy and my rights thereunder.
Patient/Patient Representative Signature: ______________________________________________ Date: ____________
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CONSENT FOR MEDICAL TREATMENT*:
I, the patient or authorized patient representative, consent to any medical examination, evaluation and treatment regarding any illness, injury, and/or health concern afecting me at any time I present to FastMed Urgent Care for medical treatment. These services may include, but are not limited, to laboratory procedures, x-ray examinations and medical and/or surgical treatment procedures.
Patient/Patient Representative Signature: ______________________________________________ Date: ____________
FOR MINOR PATIENTS:
I, the undersigned, attest that I am the custodial parent or legal guardian of the above referenced minor and hereby authorize FastMed Urgent Care to administer treatment, as it so deems necessary to the minor. In the event that the minor has received treatment at the practice before the date of this consent form, I authorize such treatment in addition to the treatment mentioned above. In no event shall my signature to any such document have any efect on this consent form.
Name of Custodial/Legal Guardian: _____________________________________ m Efective for today only.
Relationship to Minor: ______________________________________________ m Efective for today and all future visits.
Custodial/Legal Guardian Signature: __________________________________________________ Date: ________
Version April 2016
