Healthcare Urgent Care Form

HEALTHCARE URGENT CARE FORM

Please complete all sections. This form authorizes evaluation and urgent medical treatment, and permits release of necessary medical information to payors and other treating providers for the current episode of care. Incomplete fields may delay treatment.

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Chronic conditions (check all that apply): Heart disease Diabetes Asthma / COPD Hypertension

Immunosuppression: Yes    Kidney disease: Yes

Presenting Complaint

Symptom onset date:

Symptoms (check all that apply): Fever Cough Pain Nausea/Vomiting

Pain scale (0 = none; 10 = worst):    Location of pain / main problem:

Consent, Financial Responsibility, and Release

I hereby authorize the clinicians and staff of this urgent care facility to perform such diagnostic and therapeutic procedures as are deemed necessary for my care, including but not limited to examinations, laboratory testing, imaging, medication administration, wound care, and minor procedures. I understand that no guarantees have been made to me as to the results of any examination or treatment.

I authorize the release of medical information necessary to process claims and to coordinate care with other health care providers. I authorize payment of medical benefits to this facility when applicable. I acknowledge that I remain financially responsible for charges not covered or paid by my insurance, including co-payments, deductibles, and charges denied by my insurer.

If the patient is a minor or legally incapacitated, the undersigned represents that they are the parent or legal guardian and have authority to consent to treatment and to assume financial responsibility on behalf of the patient.

HIPAA Acknowledgment

I acknowledge that I have been offered a copy of the facility's Notice of Privacy Practices, which describes how my protected health information may be used and disclosed and how I can access this information. I understand that I may request restrictions on certain uses and disclosures and that such requests will be considered consistent with applicable law.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization expires on:

By signing below I certify that the information provided on this form is accurate to the best of my knowledge, that I have read and understand the consents above, and that I authorize urgent care clinicians to proceed with evaluation and treatment.

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