99-2-3E Existing Patient Method of Payment

This field is hidden when viewing the form

HID Traffic Source

this variable shows where traffic came to this form from. Query string variable is checkinid

This field is hidden when viewing the form

Visit ID

visit id passed to this form by booking

This field is hidden when viewing the form

HID Decimal Time

This field is hidden when viewing the form

Today Date

captures the date of entry for use in calculations

This field is hidden when viewing the form

HID Pull Visit

this pulls the visit record written by booking based on the Visit ID

This field is hidden when viewing the form

Patient ID

This field is hidden when viewing the form

LKUP – Patient ID Verification

used to pull record from database master visit view

This field is hidden when viewing the form

LKUP – PRIMARY Insurance

This field is hidden when viewing the form

LKUP – SECONDARY Insurance

This field is hidden when viewing the form

LKUP – New Patient State

= 1 is patient is new, 0 = patient is existing, no entry means patient is existing

This field is hidden when viewing the form

LKUP – Last Paperwork Date

This field is hidden when viewing the form

MVA Flag

This field is hidden when viewing the form

Drugscreen Flag

This field is hidden when viewing the form

DOT Flag

This field is hidden when viewing the form

Work Injury Flag

This field is hidden when viewing the form

Specialty Forms Required

This field is hidden when viewing the form

TEST New patient booking flag

This field is hidden when viewing the form

HIDDEN New Patient Flag from Booking

if 1, new patient, if 0 then existing patient

This field is hidden when viewing the form

HID FLAG exist patient confirmed

1 is new patient – 0 is existing patient??

Existing Patient Registration

Click next to verify your method of payment and, if applicable, insurance details.

This field is hidden when viewing the form

Section Break

St-2 P-1

Existing Patient Details Verification

This field is hidden when viewing the form

Primary Insurance Company Name

This field is hidden when viewing the form

Insurance Group

This field is hidden when viewing the form

Insurance Group Number

This field is hidden when viewing the form

Insurance Policyholder ID

This field is hidden when viewing the form

Secondary Insurance Company Name

This field is hidden when viewing the form

Insurance2 Group

This field is hidden when viewing the form

Insurance2 Group Number

This field is hidden when viewing the form

Insurance2 Policyholder ID

This field is hidden when viewing the form

Primary Subscriber Name

First Last

This field is hidden when viewing the form

Primary subscriebr DOB

This field is hidden when viewing the form

Secondary Subscriber Name

First Last

This field is hidden when viewing the form

Primary Insurance Details

This field is hidden when viewing the form

Primary Insurance Subscriber Details

This field is hidden when viewing the form

Secondary Insurance Details

This field is hidden when viewing the form

Secondary Insurance Subscriber Details

Method of Payment

How will you be paying for the visit today?(Required)

Patient has insurance

Patient does not have insurance and will be self pay

Is Patient using a SECONDARY insurance today in addition to their PRIMARY

Yes, Patient has a SECONDARY insurance they are using today

NOTE: We collect an ESTIMATE today of your balance due after filing with your insurance. Today’s collection is based on an initial inquiry of your benefits with your insurance company, but their quote of 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 once your claim is processed according to your plan.

Does Patient employer have workers comp insurance or will Employer be paying cash/credit card(Required)

Employer has workers comp insurance

Employer will be paying cash/credit card Today

Employer will pay other way

How will you be paying for DOT exam today(Required)

Cash/credit card

Already paid by employer national account on e-screen

How will you be paying for Pre-employment Medicine Today(Required)

Cash/credit card

Already paid by Employer on e-screen/e-passport

This field is hidden when viewing the form

Method of payment

1=health insurance, 2= other insurance, 3 is WorkerComp&employer, 4 is epassport employer paid drug screen, 5 is e-passpor DOT, 0=cash pay

Insurance:
Grp Number:
Member ID:

PRIMARY Insurance Info Correct (yes or no)?(Required)

NO CHANGE – the patient’s insurance details are correct

CHANGE NEEDED – I need to add, delete or update insurance details

Insurance:
Grp Number:
Member ID:

This field is hidden when viewing the form

Secondary Insurance Info Correct (yes or no)?(Required)

NO CHANGE – the patient’s insurance details are correct

CHANGE NEEDED – I need to add, delete or update insurance details

Primary insured (subscriber) Name:

Primary Insurance Subscriber Info Correct (yes or no)?(Required)

NO CHANGE – the patient’s insurance details are correct

CHANGE NEEDED – I need to add or update my insurance information

Primary insured (subscriber) Name:

This field is hidden when viewing the form

Secondary Insurance Subscriber Info Correct (yes or no)?(Required)

NO CHANGE – the patient’s insurance details are correct

CHANGE NEEDED – I need to add or update my insurance information

This field is hidden when viewing the form

HIDDEN Patient DOB from DB

This field is hidden when viewing the form

Change needed

This field is hidden when viewing the form

HIDDEN Patient age from DOB in DB

Self pay customers will be charged our self-pay fee up front before being seen.

NOTE: We collect an ESTIMATE today of your balance due after filing with your insurance. Today’s collection is based on an initial inquiry of your benefits with your insurance company, but their quote of 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 once your claim is processed according to your plan.

This field is hidden when viewing the form

Insurance

second half of conditional logic off the page conditional logic

Bring your insurance card into the clinic when you are called in for your visit.

Patient relationship to the Policy Holder(Required)

Describe Other Policy Holder Relationship(Required)

Insurance Policyholder (subscriber) Details – existing

Policy Holder Name(Required)

First Last

Policy Holder Cell Phone(Required)

Policy Holder Email(Required)

Policy Holder Birthdate(Required)

This field is hidden when viewing the form

patient Address

Street Address Address Line 2 City State ZIP Code

This field is hidden when viewing the form

Policy Holder Home Address

Street Address Address Line 2 City State ZIP Code

A review of your insurance payor (your insurance company) details on file some missing information or you expressed it needed updating

A review of your insurance payor (your insurance company) details on file show info is completed and you said it was correct

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

Tricare

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

Search for other insurance company – enter part of name to search

Primary Health Insurance Company Name(Required)

Select Other if your insurance is not listed

ALL Blue Cross from any state is all processed through Blue Cross of Texas

This field is hidden when viewing the form

My NON-MEDCAID, primary insurance is not listed

Click here if your NON-MEDICAID insurance is not listed

This field is hidden when viewing the form

OTHER Health Insurance Company Name if NOT LISTED ABOVE(Required)

This field is hidden when viewing the form

Insurance Company Fin Class

This field is hidden when viewing the form

Insurance Company ID

This field is hidden when viewing the form

Insurance Finclass ID1

ALL Blue Cross from any state is all processed through PO Box 660044

PO Box or Address on the back of your insurance card(Required)

This field is hidden when viewing the form

OTHER Insurance Company ADDRESS if NOT LISTED ABOVE(Required)

This field is hidden when viewing the form

Authorization ID

Insurance Member ID (Including prefix letters)(Required)

Insurance Group Number(Required)

PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES

Insurance Group Name

This field is hidden when viewing the form

Section Break

St-2 P-7

Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy(Required)

Yes

No

SECONDARY Policy Holder SAME AS PRIMARY INSURANCE policy holder – check if true

Policy Holder for SECONDARY insurance is same policy holder as the PRIMARY insurance

Patient relationship to the SECONDARY INSURANCE Policy Holder(Required)

Secondary Insurance Policy Holder

please bring in your secondary insurance card as well

This field is hidden when viewing the form

Section Break

SECONDARY Policy Holder Name(Required)

First Last

SECONDARY Policy Holder Cell Phone(Required)

SECONDARY Policy Holder Email(Required)

SECONDARY Policy Holder Birthdate(Required)

This field is hidden when viewing the form

SECONDARY Policy Holder Address – check if true

Policy Holder (the person primarily insured) lives at the same address as Patient

This field is hidden when viewing the form

SECONDARY Policy Holder Home Address

Street Address Address Line 2 City State ZIP Code

This field is hidden when viewing the form

Section Break

St-2 P-8

Secondary Insurance Coverage Details

This field is hidden when viewing the form

Who is the Network Insurance Provider for your Secondary Insurance

Blue Cross

Cigna

Aetna

United Healthcare/UMR

Medicare/Medicare Adv

Tricare

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

Secondary – Search for other insurance company – enter part of name to search

Secondary Health Insurance Company Name(Required)

Start typing the name of your insurance provider and the list will be filtered, Select Other if your insurance is not listed

My SECONDARY, NON MEDICAID insurance is not listed

Click here if your NON-MEDICAID insurance is not listed

SECONDARY Health Insurance Company Name if NOT LISTED ABOVE(Required)

SECONDARY INSURANCE PO Box or Address on the back of your insurance card(Required)

SECONDARY Insurance Company ADDRESS if NOT LISTED ABOVE

This field is hidden when viewing the form

SECONDARY Insurance Company Fin Class

This field is hidden when viewing the form

Insurance Finclass ID2

This field is hidden when viewing the form

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

This field is hidden when viewing the form

Section Break

St-2 P-9

This field is hidden when viewing the form

Section Break

This field is hidden when viewing the form

Specialty forms needed

need to add school physical wellness, DOT physical in addition to MVA, drug test

This field is hidden when viewing the form

HID – Last Paperwork Date Lookup

This field is hidden when viewing the form

Days since last signed

This field is hidden when viewing the form

HID – New paperwork required

= 1 is patient needs to re-sign or sign paperwork, 0 = patient is existing and paperwork is within 1 year

This field is hidden when viewing the form

Place in line

Good News – Your Paperwork on File is still valid since you signed within the last year

We will verify a few of your details from your records and get you on the way!

We Found the Patient’s Signed Paperwork on File

Our paperwork is valid for one year, and the patient’s paperwork has expired. We will verify a few of your details from prior visits and get you new paperwork to sign.

Prepping Paperwork for Signatures

Next section is to sign your visit paperwork. Our paperwork is valid for one year. Click Next below to continue.

This field is hidden when viewing the form

Section Break

St-2 P-10

This field is hidden when viewing the form

Check for duplicates

Existing patient method of payment done, click next to continue

CMed Registration – Method of Payment

Existing Patient Registration

Section Break

Existing Patient Details Verification

Method of Payment

Insurance

Insurance Policyholder (subscriber) Details – existing

PRIMARY Insurance Policy Details

Section Break

Secondary Insurance Policy Holder

Section Break

Section Break

Secondary Insurance Coverage Details

Section Break

Section Break

Good News – Your Paperwork on File is still valid since you signed within the last year

We Found the Patient’s Signed Paperwork on File

Prepping Paperwork for Signatures

Section Break