99-2-3E Existing Patient Method of Payment – CommunityMed Family Urgent Care

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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

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HID Pull Visit

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

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LKUP – Patient ID Verification

used to pull record from database master visit view

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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

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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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TEST New patient booking flag

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HIDDEN New Patient Flag from Booking

if 1, new patient, if 0 then existing patient

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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.

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Existing Patient Details Verification

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Primary Insurance Company Name

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Insurance Group

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Insurance Group Number

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Insurance Policyholder ID

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Secondary Insurance Company Name

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Insurance2 Group

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Insurance2 Group Number

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Insurance2 Policyholder ID

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Primary Subscriber Name

First Last

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Secondary Subscriber Name

First Last

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Primary Insurance Details

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Primary Insurance Subscriber Details

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Secondary Insurance Details

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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

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:

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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:

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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

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HIDDEN Patient DOB from DB

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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.

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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)

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A review of your insurance subscriber (primary person on your policy) details on file show info is completed and you said it was correct

A review of your insurance subscriber (primary person on your policy) details on file some missing information or you expressed it needed updating

Insurance Policyholder (subscriber) Details

Policy Holder Name(Required)

First Last

Policy Holder Cell Phone(Required)

Policy Holder Email(Required)

Policy Holder Birthdate(Required)

Policy Holder Social Security Number

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patient Address

Street Address Address Line 2 City State ZIP Code

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Policy Holder Address – check if true

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

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Policy Holder Home Address

Street Address Address Line 2 City State ZIP Code

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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

Start Typing Primary Health Insurance Company Name(Required)

Select Other if your insurance is not listed

My NON-MEDCAID, primary insurance is not listed

Click here if your NON-MEDICAID insurance is not listed

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

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Insurance Company Fin Class

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Insurance Company ID

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Insurance Finclass ID1

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

OTHER Insurance Company ADDRESS if NOT LISTED ABOVE(Required)

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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

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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

SECONDARY Policy Holder Name(Required)

First Last

SECONDARY Policy Holder Cell Phone(Required)

SECONDARY Policy Holder Email(Required)

SECONDARY Policy Holder Birthdate(Required)

SECONDARY Policy Holder Social Security Number

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SECONDARY Policy Holder Address – check if true

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

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SECONDARY Policy Holder Home Address

Street Address Address Line 2 City State ZIP Code

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Secondary Insurance Coverage Details

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Who is the Network Insurance Provider for your Secondary Insurance

Blue Cross

Cigna

Aetna

United Healthcare/UMR

Medicare/Medicare Adv

Tricare

Other

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

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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

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Specialty forms needed

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

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HID – Last Paperwork Date Lookup

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Days since last signed

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HID – New paperwork required

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

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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.

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Check for duplicates