CMed – Registration Forms for Signatures

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HIDDEN Visit ID

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Decimal Time

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Today Date

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Source

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Filaname Today Date

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Visit_ID_Lookup

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Lookup Visit Data

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Lookup Patient Data

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GuardianID1

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Lookup guardian Data

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In Parkinglot Flag

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Patient DOB Date

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Patient Age

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Patient Name

First Last

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Patient Mobile

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Patient Email

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Visit Reason

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Visit Reason EMR id

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Clinic

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Clinic Name

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Clinic Address

Street Address Address Line 2 City State ZIP Code

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HIDDEN Clinic front desk cell Phone

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Visit Date

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Visit TIme hour

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Visit Time Label

We have Verified your Paperwork Dates

You have signed paperwork in the past 12 months, so we can move to the next step

Lets get your electronic signature

These are the permission to treat and HIPAA permission. Both are valid for 1 year (so you wont have to sign when you come back)

We have a new system and need new paperwork signatures

Apologies, with our new system we need an updated permission to treat and HIPAA permission. Both are valid for 1 year (so you wont have to sign when you come back)

I agree to electronic signatures on documents(Required)

I agree and understand that by selecting below the Electronic Signature Acknowledgment and Consent, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound.

I acknowledge and consent to Electronic Signature

New Patient Signatures

Consent and Permission

I authorize the release of information necessary to process this claim and assign benefits payable for services directly to CommunityMed PCP, PLLC or CommunityMed PLLC, herein referred to as CommunityMed Urgent Care. I authorize the release of any medical information necessary for treatment by my current or future physician or health care provider. I authorize CommunityMed Urgent Care to release to my insurance company any medical information that may be necessary to process my insurance claim. CommunityMed Urgent Care is an urgent care facility. At the time of your visit payments will be collected based on your Urgent Care benefits and your insurance carrier will be billed. I understand that in the event my insurance company denies this claim, I will be held financially responsible for all charges, including any collection fees, court costs and all attorneys’ fees incurred by CommunityMed Urgent Care in collecting a delinquent account.

I am the Guarantor (Person financially responsible for any balance not paid by insurance). If the patient is under 18 years of age, I am also a legal guardian for the minors patient and able to sign medical permissions on their behalf.

Responsible Adult Signing this form – Guardian

First Last

Responsible Adult Signing this form – Patient

First Last

Type Name for Electronic Signature – Consent and Permission(Required)

Typing your name here is an acknowledgement that you accept electronic signatures as legally binding, and your typing of your name here is a second form of your electronic signature.

Consent Signature Date

Patient HIPAA Acknowledgment and Consent Form

Responsible Adult signing this form – Guardian

First Last

Responsible Adult signing this form – Patient

First Last

Healthcare information may be released to any person or entity liable for payment on the Patient’s behalf to verify coverage or payment questions, or for any other purpose related to benefit payment. I hereby permit this practice and the health professionals involved in my care to release healthcare information for purposes of treatment, payment, or healthcare operations. As provided by Privacy Rule Section 164.522(b), I hereby allow the Practice to communicate via phone, email, postal mail and text to the address, email address and phone numbers provided on my intake form.

Consent to Treatment: I understand that a medical practitioner at my request will order all test and treatment at CommunityMed Urgent Care. I understand that medicine is not an exact science and that there is no guarantee that the outcome of my treatment will be what I want it to be. Knowing this, and agreeing to this, I request to be a patient at CommunityMed Urgent Care. I consent to all necessary testing and treatment, including procedures and routine immunizations, while I am a patient at CommunityMed Urgent Care on this date through a full calendar year from this date. If this paperwork is being completed for my minor child I consent to all necessary testing and treatment while he / she is a patient at CommunityMed Urgent Care on this date through a full calendar year from this date. I consent to photographs being taken for the purpose of medical treatment and diagnosis. I authorize CommunityMed Urgent Care to retain for testing and/or dispose of any specimen or tissue taken from the above-named patient.

Notice of Privacy Practices: I acknowledge that I have reviewed the clinic’s posted Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

Accidental Exposure of Healthcare Workers: I understand that state law provides for, and I agree, that if any healthcare worker is exposed to my blood or other bodily fluids to allow CommunityMed Urgent Care to perform tests on my blood or other bodily fluids to determine the presence of any communicable diseases, including but not limited to, hepatitis, human immunodeficiency virus (AIDS), and syphilis. I understand that such testing is necessary to protect those who will be caring for me while I am a patient at CommunityMed Urgent Care. I understand that the results of test taken under these circumstances do not become part of my medical record.

THE FOLLOWING INDIVIDUALS MAY ACCESS THIS PATIENTS HEALTH INFORMATION AND REQUEST RECORDS ON THE PATIENT’S BEHALF:

Authorized Individuals

List names separated by commas

Authorized Individual Relationships

Enter the authorized individuals relationships separated by commas

THE FOLLOWING INDIVIDUALS MAY AUTHORIZE MEDICAL TREATMENT ON BEHALF OF MY MINOR CHILD: ** TO BE COMPLETED ONLY IF PATIENT IS A MINOR CHILD **

Individuals Authorized to Approve Minor Medical Care

List names separated by commas

Minor Medical Care – Relationship of Authorized Individual(s) to the Patient

Enter the authorized individuals relationships separated by commas

Type Name for Electronic Signature – HIPAA and Consent(Required)

Typing your name here is an acknowledgement that you accept electronic signatures as legally binding, and your typing of your name here is a second form of your electronic signature.

Hipaa Signature Date

99-4 Signature Forms

CMed – Registration Forms for Signatures

We have Verified your Paperwork Dates

Lets get your electronic signature

We have a new system and need new paperwork signatures

New Patient Signatures

Consent and Permission

Patient HIPAA Acknowledgment and Consent Form

Workplace Medicine (such as Drug & BAT Testing)

Occ Med Registration

Registration

Pres Next to continue on for uploading any images

Pres Next to continue on for uploading any images

Pres Next to continue on for uploading any images

Workplace & DOT

Pull Data for Clockwize

Section Break