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99-2-3 – Method of Payment
CMed Registration – Method of Payment
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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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DO WE NEED? HID Arrived
this variable is set to 4 when patient has arrived in the parking lot. the querystring variable is arvd. Default value is 0
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Visit ID
visit id passed to this form by booking
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HID Current Hour
hideme {current_hour}
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HID Current Minutes
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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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Tomorrow 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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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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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??
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St-2 P-1
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
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
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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
Bring your insurance card into the clinic when you are called in for your visit.
Patient relationship to the Policy Holder
(Required)
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)
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St-2 P-5
Insurance Coverage 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
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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
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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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 Social Security Number
(Required)
Your selected insurance type requires the subscriber social security number
POLICY HOLDER Social Security Number
(Required)
Your selected insurance type requires the subscriber social security number
Search for other insurance company – type part of insurance company name
ALL Blue Cross insurances processes through a single Blue Cross
Primary Health Insurance Company Name
(Required)
Select Other if your insurance is not listed
–Select If Your Insurance Is Listed–
– Fill Out Other Fields –
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My NON-MEDCAID, primary insurance is not listed
Click here if your NON-MEDICAID insurance is not listed
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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
ALL Blue Cross insurances processes through PO Box 660044
PO Box or Address on the back of your insurance card
(Required)
–Select Insurance Address if listed —
– Fill Out Other Fields –
OTHER Insurance Company ADDRESS if NOT LISTED ABOVE
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Is this insurance an HMO?
(Required)
Yes
No
I Don’t Know
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Authorization ID
Some HMOs require approval to go to Urgent Care
If your HMO requires this pre-authorization and you did not already get the approval/referral,
we will work with your insurance to get the approval during or after your visit.
We have no issue with most HMOs. If your HMO does not allow a referral during or after the visit, we will bill you for the visit at the discounted contract rate we have with your insurance. Please hop in and talk to the front desk if you have any questions. We want to make this as easy as possible.
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If you have an HMO and, for some reason, they do not allow referral for this visit:
(Required)
If you did not already get a referral from your HMO AND If your HMO does not allow us to get a referral, by checking here I agree to pay the discounted contract rate for this visit
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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St-2 P-7
Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy
(Required)
Yes
No
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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)
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
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)
MM slash DD slash YYYY
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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
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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Secondary Insurance Coverage Details
Who is the Network Insurance Provider for your SECONDARY Insurance
(Required)
Blue Cross
Cigna
Aetna
United Healthcare/UMR
Medicare/Medicare Adv
Tricare
Other
PATIENT Social Security Number
(Required)
Your selected insurance type requires subscriber social
SECONDARY POLICYHOLDER Social Security Number
(Required)
Your selected insurance type requires subscriber social
Secondary – Search for other insurance company – type part of insurance company name
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
–Select If Your Insurance Is Listed–
– Fill Out Other Fields –
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)
–Select Insurance Address if listed —
– Fill Out Other Fields –
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
(Required)
PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
SECONDARY Insurance Group Name
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St-2 P-9
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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
MM slash DD slash YYYY
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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 changed systems and need you to sign new paperwork
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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St-2 P-10
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Check for duplicates
