Registration – Patient Demographics – 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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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

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Tomorrow 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 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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Patient Information

Patient Name(Required)

First Last

Patient Date of Birth(Required)

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

Your Legal Marital Status

Single

Married

Your Biological Sex(Required)

M

F

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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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Insurance Coverage Details

Policy Holder Name(Required)

First Last

Policy Holder Cell Phone

Policy Holder Email

Policy Holder Birthdate(Required)

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

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)

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

PO Box or Address on the back of your insurance card

OTHER Insurance Company ADDRESS if NOT LISTED ABOVE

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

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

SECONDARY Policy Holder Email

SECONDARY Policy Holder Birthdate(Required)

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

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

Registration – Patient Demographics

Existing Patient Registration

New Patient Registration

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Existing Patient Details Verification

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Patient Information

Address Info

Patient Demographics

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

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

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Method of Payment

Insurance

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Insurance Coverage Details

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PRIMARY Insurance Policy Details

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Secondary Insurance Policy Holder

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Secondary Insurance Coverage Details

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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

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