Download HERE.pdf

It includes:

Patient Information:

Last Name, First Name, Middle Name, Ethnicity, SS#, Sex (Male/Female), Date of Birth, Marital Status, Address, City, State, Zip Code, Home Phone Number, Cell Phone Number, Email, and Employment details.

Emergency Contact:

Emergency Contact Name, Relationship to Patient, Emergency Contact Phone Number.

Insurance Information:

Relationship to Patient (Self/Mother/Father/Other), Policyholder Last Name, First Name, SS#, Sex, Date of Birth, Insurance Company, Member ID, Group Name, and Group Number.

Preferred Pharmacy:

Pharmacy Name and Phone Number.

Consent for Treatment:

Patient authorizes AnytimeMD Urgent Care to provide necessary medical treatment, including urgent care, examinations (e.g., X-rays), lab procedures, medications, minor surgeries, etc.
Acknowledges responsibility for payment of non-covered services and laboratory testing charges.

Financial Responsibility:

Patient responsible for arranging payment for medical services; insurance benefits to be paid directly to AnytimeMD Urgent Care.
Authorization to release information necessary for insurance claim processing.

Acknowledgement of Privacy Rights:

Patient acknowledges receipt of AnytimeMD Urgent Care's Notice of Privacy Practices and Individual Rights.

Release of Medical Information & Records Consent:

AnytimeMD Urgent Care may contact patient by phone or email with Protected Health Information (PHI), with consent.
Patient can opt-out of phone or email communication for PHI.

Chief Complaint:

Primary reason for the patient's visit.

Primary Care Physician:

Name and phone number of the patient's primary care physician.

Allergies and Medications:

List of current allergies and any medications the patient is taking.