Registration – Patient Demographics

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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

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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

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??

Existing Patient Registration

Click next to verify your patient contact, insurance, and guardian (for minors) details.

New Patient Registration

Click next to enter your patient contact, insurance, and guardian (for minors) details.

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Existing Patient Details Verification

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Is this the patient's current street address?

Street Address on file:

Patient Address correct (yes or no)?(Required)

NO CHANGE - that address is correct

CHANGE NEEDED - I need to update my address

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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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Method of Payment

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FLAG Method of Payment

Method of Payment:

Method of payment correct?(Required)

NO CHANGE - this is the correct way patient is paying today

CHANGE NEEDED - I need to change how we are paying for today's visit

Insurance Details on File:
Insurance Company:
Insurance Group:
Group Number:
Insurance Member No:

NOTE: We collect an ESTIMATE today of your balance due after filing with your insurance. Today's collection is based on an 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.

Insurance 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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Patient (or Parent's) Email

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Patient (or Parent's Cell Phone)

Contact Info on File:
Patient (or parent) Email:
Patient (or parent) Mobile Phone:

Patient contact Info correct (yes or no)?(Required)

Includes name, Date of birth, email, cell number

NO CHANGE - the patient's contact details are correct

CHANGE NEEDED - I need to update the patient's contact information

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Guarantor 1 ID

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Guarantor 2 ID

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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

Adult Guardians on file for Patient - select if you are listed

Please fill out other fields.

Parent/Guardian Info correct (yes or no)?(Required)

NO CHANGE - the patient's Guardian details are correct, and I am the person selected

CHANGE NEEDED - I am the person selected, but I need to update some of my details

CHANGE NEEDED - I am not listed and need to be added as a guardian

ERROR

Please either select yourself from the guardian list or choose "No, I am not listed and need to be added as a guardian"

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Patient Information

Patient Name(Required)

First Last

Patient Date of Birth(Required)

MM slash DD slash YYYY

Patient (or parent for minors) Mobile Phone(Required)

Patient (or parent for minors) Email(Required)

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Patient Age

Address Info

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Patient Demographics

Patient Biological Sex(Required)

Male

Female

Patient Marital Status(Required)

Married

Single

N/A

Patient (or Parent for minors) Social Security Number(Required)

Information is used for billing - will be kept confidential

Family Physician

Preferred Pharmacy

Description of Pharmacy location

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LKUP - HIDDEN Front Desk Phone

Please verify the GUARANTOR (Adult responsible for patient) information below

and correct any information that is inaccurate.

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)

Because the patient is a minor, they require an adult who is legally able to sign permission forms for the patient (usually the parent or guardian). The remaining information on this page is to be completed by this adult. The guarantor is the Adult, responsible for the Minor, who is signing the form.

Parent Name (Guarantor)(Required)

First Last

Your Relationship to Patient(Required)

Parent Date of Birth(Required)

We need this to verify your identity

MM slash DD slash YYYY

Your Legal Marital Status

Single

Married

Your Biological Sex(Required)

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Parent age

current age, no decimal needed

Guarantor Address

Check here if Patient lives at same address as Patient

Your Current Address(Required)

Street Address Address Line 2 City State ZIP Code

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Method of Payment

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

Patient has insurance

Patient does not have insurance and will be paying cash

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.

Because your injury is the result of a motor vehicle accident - health insurance does not cover the injury

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Do you want to file with your automobile insurance to pay for this Motor Vehicle Accident injury?

Yes

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Does Patient have motor vehicle insurance and does that insurance have Personal Injury Protection?

Yes

Unsure

Because you are unsure or do not have personal injury protection on your automobile coverage, we will need to collect payment today in cash/check/credit card for this visit.

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)

Describe Other Policy Holder Relationship(Required)

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Insurance Coverage Details

Policy Holder Name(Required)

First Last

Policy Holder Cell Phone

Policy Holder Email

Enter Email Confirm Email

Policy Holder Birthdate(Required)

MM slash DD slash YYYY

Policy Holder Social Security Number(Required)

Policy Holder Address - check if true

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

Policy Holder Home Address

Street Address Address Line 2 City State 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

Blue Cross

Cigna

Aetna

United Healthcare/UMR

Medicare/Medicare Adv

Tricare

Other

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FIRST 2 LETTERs of Primary Health Insurance Company Name

On your insurance card, what are the first 2 letters of the name of your insurance (e.g. Cigna would be Ci)

Start Typing Primary Health Insurance Company Name

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

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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

OTHER Insurance Company ADDRESS if NOT LISTED ABOVE

Is this insurance an HMO?(Required)

Yes

I Don't Know

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Authorization ID

Some HMOs require approval to go to Urgent CareIf 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.

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

Yes

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

SECONDARY Policy Holder Email

Enter Email Confirm Email

SECONDARY Policy Holder Birthdate(Required)

MM slash DD slash YYYY

SECONDARY Policy Holder Social Security Number(Required)

SECONDARY Policy Holder Address - check if true

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

SECONDARY Policy Holder Home Address

Street Address Address Line 2 City State ZIP Code

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Secondary Insurance Coverage Details

FIRST 2 LETTERs of SECONDARY Health Insurance Company Name

On your insurance card, what are the first 2 letters of the name of your SECONDARY insurance (e.g. Cigna would be Ci)

Secondary Health Insurance Company Name

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

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

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

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 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