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99-1-2E Existing Patient Confirm Data
Existing Patient Confirmation
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HID Traffic Source
this variable shows where traffic came to this form from. Query string variable is checkinid
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Visit ID
visit id passed to this form by booking
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HID Decimal Time
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Today Date
captures the date of entry for use in calculations
MM slash DD slash YYYY
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HID Pull Visit
this pulls the visit record written by booking based on the Visit ID
– Fill Out Other Fields –
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Patient ID
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LKUP – Patient ID Verification
used to pull record from database master visit view
– Fill Out Other Fields –
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LKUP – New Patient State
= 1 is patient is new, 0 = patient is existing, no entry means patient is existing
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LKUP – Last Paperwork Date
MM slash DD slash YYYY
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MVA Flag
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Drugscreen Flag
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DOT Flag
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Work Injury Flag
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Specialty Forms Required
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pat Date for age
MM slash DD slash YYYY
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Patient Age
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HIDDEN New Patient Flag from Booking
if 1, new patient, if 0 then existing patient
Existing Patient Registration
Click next to verify your method of payment and, if applicable, insurance details.
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Existing Patient Details Verification
Method of Payment
How will you be paying for the visit today?
(Required)
Patient has insurance – urgent care
Patient does not have insurance and will be self pay – urgent care
Patient is here for work injury follow up visit
Patient is here for a Employer paid service (e.g. drug screen or DOT)
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Complete record
Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy
(Required)
Yes
No
Collecting insurance payment today
NOTE: We collect an ESTIMATE today of your balance due after filing with your insurance. Verification of your benefits is not always an accurate reflection of benefits or payment.
Once your claim is processed, You may owe additional funds or receive a refund.
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HIDDEN Patient DOB from DB
MM slash DD slash YYYY
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HIDDEN Patient age from DOB in DB
The patient and payment Info ABOVE is Correct (yes or no)?
(Required)
NO CHANGE – the patient’s PATIENT, GUARDIAN, and PAYMENT details are correct
CHANGE NEEDED – I need to add, delete or update PATIENT, GUARDIAN, or PAYMENT details
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Demographics require update
PATIENT information ABOVE is correct (yes or no)?
(Required)
NO CHANGE – the patient’s details are correct
CHANGE NEEDED – I need to add, delete or update details
Patient Details
Patient Name
(Required)
First
Last
Patient Date of Birth
(Required)
MM slash DD slash YYYY
Confirm Patient (or parent for minors) Mobile Phone
(Required)
Confirm Patient (or parent for minors) Email
(Required)
Address Info
Confirm the address below
(Required)
I confirm the address below is my legal address AND THE ADDRESS ON MY DRIVERS LICENSE
I confirm the address below is my legal address BUT IT IS NOT the address on my drivers license, my license is wrong
PATIENT Legal Address (address in public records e.g. drivers license)
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
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Patient Demographics
For Identification purposes, please enter the social security number below. We hold this value in confidence.
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Parent or Guardian Social Security Number
Information is used for billing – will be kept confidential
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Patient Social Security Number
Information is used for billing – will be kept confidential
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Current Preferred Pharmacy on File
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Would you like to change Preferred Pharmacy?
Yes
No
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Select Pharmacy
We have a new prescription tool, and need you to select your pharmacy below – apologies
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Name of Preferred Pharmacy
What is the name or partial name of your preferred pharmacy (For example Walgreens)
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In what city is that pharmacy?
What is the name of the city where the Pharmacy is located?
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Select Preferred Pharmacy from Filtered Options
–Select Pharmacy from list —
– Fill Out Other Fields –
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guardian require update
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number of guardians
Select which guardian is with the patient today from multiple guardians
First Choice
Second Choice
Third Choice
The MINOR patient Guardian information ABOVE is Correct (yes or no)?
(Required)
NO CHANGE – the patient’s GUARDIAN details are correct
CHANGE NEEDED – I need to add, delete or update GUARDIAN details
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Guardian ID from Today's Registration
ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)
Parent Name (Guardian)
(Required)
First
Last
Parent Date of Birth
(Required)
We need this to verify your identity
MM slash DD slash YYYY
Your Relationship to Patient
(Required)
Parent/Step Parent
Spouse
Legal Guardian
Other
Describe Other
Your Legal Marital Status
Single
Married
Guardian Parent Phone
(Required)
Guardian Parent Email
(Required)
Guardian address same
Guardian has same address as PATIENT
Guardian Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
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insurance1 require update
PRIMARY Insurance Info ABOVE is Correct (yes or no)?
(Required)
NO CHANGE – the patient’s PRIMARY INSURANCE details are correct
CHANGE NEEDED – I need to add, delete or update PRIMARY INSURANCE details
Primary Insurance
Bring your insurance card into the clinic when you are called in for your visit.
Patient relationship to the Policy Holder
(Required)
— Select patient relationship to policyholder –
Patient is the Policy Holder
Parent/Guardian filling out this paperwork is the Policy Holder
A DIFFERENT Parent/Guardian who is NOT filling out this paperwork is the Policy Holder
Spouse of Patient is the Policy Holder
Other
Describe Other Policy Holder Relationship
(Required)
Insurance Policyholder (subscriber) Details
Policy Holder Name
(Required)
First
Last
Policy Holder Cell Phone
(Required)
Policy Holder Email
(Required)
Policy Holder Birthdate
(Required)
MM slash DD slash YYYY
PRIMARY Insurance Policy Details
NOTE : WE ARE NOT in network and CAN NOT ACCEPT MEDICAID as a form of insurance. As a MEDICAID Patient, you CAN PAY CASH, but you CANNOT FILE for reimbursement for a visit with us.
Who is the Network Insurance Provider for your Primary Insurance
(Required)
Blue Cross
Cigna
Aetna
United Healthcare/UMR
Medicare/Medicare Adv
Military
Other
PATIENT HOLDER Social Security Number
(Required)
The insurance you selected requires the patient social security number
POLICY HOLDER Social Security Number
(Required)
The insurance you selected requires the policy holder social security number
Type PRIMARY Insurance Company Name as it appears on the card
(Required)
Type PRIMARY Insurance Company PO BOX or ADDRESS as it appears on the card
(Required)
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Insurance Company ID
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Insurance Company Fin Class
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Insurance Finclass ID1
Insurance Member ID (Including prefix letters)
(Required)
Insurance Group Number
(Required)
PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
Insurance Group Name
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insurance2 require update
SECONDARY Insurance Info ABOVE is Correct (yes or no)?
(Required)
NO CHANGE – the patient’s SECONDARY INSURANCE details are correct
CHANGE NEEDED – I need to add, delete or update SECONDARY INSURANCE details
Patient relationship to the SECONDARY INSURANCE Policy Holder
(Required)
— Select patient relationship to Policyholder —
Patient is the Policy Holder
Parent/Guardian filling out this paperwork is the Policy Holder
A DIFFERENT Parent/Guardian who is NOT filling out this paperwork is the Policy Holder
Spouse of Patient is the Policy Holder
Other
Secondary Insurance Policy Holder
SECONDARY Policy Holder Name
(Required)
First
Last
SECONDARY Policy Holder Cell Phone
(Required)
SECONDARY Policy Holder Email
(Required)
SECONDARY Policy Holder Birthdate
(Required)
MM slash DD slash YYYY
Secondary Insurance Coverage Details
Who is the Network Insurance Provider for your SECONDARY Insurance
Blue Cross
Cigna
Aetna
United Healthcare/UMR
Medicare/Medicare Adv
Military
Other
PATIENT Social Security Number
(Required)
The insurance type you selected requires the patient social security number
SECONDARY POLICYHOLDER Social Security Number
(Required)
The insurance type you selected requires the policyholder social security number
Type SECONDARY Insurance Company Name as it appears on the card
(Required)
Type SECONDARY Insurance Company PO BOX or ADDRESS as it appears on the card
(Required)
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SECONDARY Insurance Company Fin Class
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Insurance Finclass ID2
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SECONDARY Insurance Company ID
SECONDARY Insurance Member ID (Including prefix letters)
(Required)
SECONDARY Insurance Group Number
PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
SECONDARY Insurance Group Name
