University Health and Urgent Care - Online Healthcare Forms

Patient Information

Last Name(*)

Please type your last name.

Middle Name

Please type your middle name.

First Name(*)

Please type your first name.

Date of Birth(*)

Please fill out

Sex(*)

male

female

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Marital Status

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Street Address 1(*)

Please write your current home address

Street Address 2

City(*)

State(*)

Zip Code(*)

E-mail(*)

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Can we contact you in future via this email address?(*)

yes

no

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May we send a text message with clinic updates and/or secure links to test results? You will have the option to opt-out at any time and will not receive more than two per month.(*)

yes

no

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Phone Number

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Mobile Number(*)

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Can we leave a voicemail regarding NORMAL results?(*)

yes

no

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Occupation

Please type your current profession

Employer

Please type provide your current employer's company name

How did you hear about us?:(*)

Reason of Visit(*)

Please state your purpose of visit

Insurance Holder Information

Are you the policy holder?

I am the policy holder

I am not the policy holder

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Medical Insurance Company

Policy Holder's Full Name

Policy Number

Policy Holder's Social Security Number

Policy Holder's Address

Policy Holder’s Address is the same as Home Address on the previous page

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Please don't fill out the field below if you ticked the checkbox above

Policy Holders Date of Birth

The Policy Holder’s Date of Birth is the same as Patient Info DOB

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Please don't fill out the field below if you ticked the checkbox above

Please fill out

Emergency Notification

In case of emergency, notify

Please provide a full name of an emergency contact

Contact Number

Please provide an emergency contact number

Relationship

Please fill out this portion

Date Today

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PAYMENT AND LATE FEE

Thank you for choosing our providers to help care for your urgent care and preventive medicine needs.

At University Health and Urgent Care, we are committed to providing our patients with exceptional medical care.

All evaluations will be submitted to your insurance company for reimbursement.

Sometimes, the insurance company does not reimburse the full cost of the exam and testing that are done.

The insurance company will send you and UHUC an explanation of benefits and list the money the patient owes the facility as "PATIENT RESPONSIBILITY."

LATE FEE:

If there is an outstanding balance, we will then send you a responsibility letter with the amount of money you owe for the date of service at our office.

We expect that you pay the balance within 30 days of receipt. If we do not receive your payment within 30 days, we will charge a $15.00 late fee.

We will add $15.00 every 30 days. After 90 days, if we have not received payment your account will be sent to collections.

Current Address:(*)

Please type your full current address.

Full Name:(*)

Please type your full current address.

Signature(*)

Sign Above

Please sign here

Date Signed

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ASSIGNMENT OF INSURANCE BENEFITS AND NOTICE OF PRIVACY PRACTICES AND THE RELEASE OF INFORMATION

If your insurance is an HMO, POS, or MC plan, and University Health and Urgent Care/Advanced Perioperative Medicine is not listed as your primary care provider, I the undersigned understand and agree that I am fully responsible for any out-of-network and deductible payments that are not covered by your insurance.

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or my dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered, or for services to be rendered without obtaining my signature on each claim to be submitted for myself and/or my dependents and that I will be bound by this signature as though the undersigned had personally signed the particular claim.

I understand and agree that should the insurance card I present today be invalid, expired, incorrect in any way, or not the appropriate card for my current insurance, I will be personally and financially responsible for any charges incurred as a result of such error. I also agree that it is my responsibility to present the correct insurance card at the time of each visit. I further agree to accept responsibility for any bills incurred that are denied by my current insurance company for any reason including timely filing as a result of my failing to present an appropriate insurance card or presenting inaccurate personal information, including old or invalid insurance cards, licenses, or other identifying information.

I also understand and agree that it is within the rights of University Health and Urgent Care/Advanced Perioperative Medicine to collect any outstanding charges by billing me personally through any collection method including phone, mail, or collection agency. Should such delinquent accounts remain unpaid after 60 days, University Health and Urgent Care/Advanced Perioperative Medicine or its agents may forward such accounts to a collection agency, and such accounts may be reported to a national collection bureau. I hold University Health and Urgent Care/Advanced Perioperative Medicine, its agents, or assignees harmless for all damages resulting from such action.

I understand and agree that if I do not have insurance, I will be responsible for all charges incurred today due in full at the end of my visit unless other arrangements were made before my visit.

I hereby authorize my insurance carrier to pay, and hereby assign directly to University Health and Urgent Care Advanced Perioperative Medicine, all benefits, if any otherwise payable to me for the facility's services as described on the attached forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid to University Health and Urgent Care, will be credited to my account by the above-said assignment.

Your signature below acknowledges that you read and agree to the above and that you have received the Notice of Privacy Practices and the Release of Information.

If the patient is a minor (under the age of 18), please sign on their behalf.

Print Name:(*)

Please type your full name.

Signature(*)

Sign Above

Please sign here

Date Signed

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RELEASE OF INFORMATION

Telephone number where we can best reach you:(*)

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We will always speak to you directly about ABNORMAL test results.

Please list below the authorized individuals with whom we may discuss your medical information.

Authorized Person #1

Full Name:

Please provide a full name of a person

Contact Number:

Relationship:

Please fill out this portion

Authorized Person #2

Full Name:

Please provide a full name of a person

Contact Number:

Relationship:

Please fill out this portion

Your signature below acknowledges that you have received the Notice of Privacy Practices and the Release of Information.

If the patient is a minor (under the age of 18), please sign on their behalf.

Patient is under 18

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Full Name(*)

Please type your full name.

Signature(*)

Sign Above

Please sign here

If you are a new patient or have been treated by another physician, please complete a medical release form to have medical records forwarded to University Health and Urgent Care so we can provide the best care for you.

Do you feel unsafe, or have you been harmed in a physical, emotional, or sexual manner?(*)

Yes

No

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If yes, please describe

IMMUNIZATIONS / VACCINATIONS

Please let us know your vaccination status for the following vaccines. Either tick Never if you have not been vaccinated or select the date of vaccination received.

Pneumonia

Never

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Please select "Never" if you have not been vaccinated or select the date of vaccination from the drop-down

Month

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Year

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Hepa A

Never

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Please select "Never" if you have not been vaccinated or select the date of vaccination from the drop-down

Month

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Year

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Hepa B

Never

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Please select "Never" if you have not been vaccinated or select the date of vaccination from the drop-down

Month

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Year

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Varicella

Never

Invalid Input

Please select "Never" if you have not been vaccinated or select the date of vaccination from the drop-down

Month

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Year

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Shingles

Never

Invalid Input

Please select "Never" if you have not been vaccinated or select the date of vaccination from the drop-down

Month

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Year

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Tetanus Booster (Tdap)

Never

Invalid Input

Please select "Never" if you have not been vaccinated or select the date of vaccination from the drop-down

Month

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Year

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PREVENTATIVE CARE

Please indicate the status of the following preventative tests. Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Colonoscopy

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

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Bone Density Test (DXA)

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

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Cholesterol Test

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

Invalid Input

Year

Invalid Input

Prostate Test (PSA)

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

Invalid Input

Pap Smear

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

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Mammogram

Never

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Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

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HIV Test

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

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Hepatitis C Screen Test

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

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TB Skin Test

Never

Invalid Input

Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

Month

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Year

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Date Today

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SPECIALISTS INVOLVED IN YOUR CARE

Primary Care Doctor

Physician's Name

Clinic Address

Phone Number

Pharmacy

Pharmacy Name

Pharmacy's Phone Number

Pharmacy Address

Please write your current home address

Other specialists:

Others:

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FAMILY HISTORY

Do you wish to pay your appointment online?

yes

no

UHUC Patient Forms

PAYMENT AND LATE FEE

ASSIGNMENT OF INSURANCE BENEFITS AND NOTICE OF PRIVACY PRACTICES AND THE RELEASE OF INFORMATION

RELEASE OF INFORMATION

Please list below the authorized individuals with whom we may discuss your medical information.

Your signature below acknowledges that you have received the Notice of Privacy Practices and the Release of Information.

If the patient is a minor (under the age of 18), please sign on their behalf.

If you are a new patient or have been treated by another physician, please complete a medical release form to have medical records forwarded to University Health and Urgent Care so we can provide the best care for you.

PATIENT'S MEDICAL CONDITIONS

SURGICAL HISTORY

HABITS AND ACTIVITIES

ALLERGIES

IMMUNIZATIONS / VACCINATIONS

Please let us know your vaccination status for the following vaccines. Either tick Never if you have not been vaccinated or select the date of vaccination received.

PREVENTATIVE CARE

Please indicate the status of the following preventative tests. Please select "Never" if you have never had the test or select the date of your last test from the drop-down.

SPECIALISTS INVOLVED IN YOUR CARE

Primary Care Doctor

Pharmacy

Other specialists:

FAMILY HISTORY