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CommunityMed Family Urgent Care –
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Registration – Patient Demographics

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this variable shows where traffic came to this form from. Query string variable is checkinid
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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 passed to this form by booking
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hideme {current_hour}
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captures the date of entry for use in calculations
MM slash DD slash YYYY
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captures the date of entry for use in calculations
MM slash DD slash YYYY
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this pulls the visit record written by booking based on the Visit ID
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used to pull record from database master visit view
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= 1 is patient is new, 0 = patient is existing, no entry means patient is existing
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MM slash DD slash YYYY
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if 1, new patient, if 0 then existing patient
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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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Street Address on file:
Patient Address correct (yes or no)?(Required)
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Method of Payment:
Method of payment correct?(Required)
Insurance Details on File:
Insurance Company:
Insurance Group:
Group Number:
Insurance Member No:
Insurance Info Correct (yes or no)?(Required)
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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
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MM slash DD slash YYYY
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Adult Guardians on file for Patient - select if you are listed

Please fill out other fields.

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

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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)
MM slash DD slash YYYY
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Address Info

Patient Address(Required)

Patient Demographics

Patient Biological Sex(Required)
Patient Marital Status(Required)
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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)
We need this to verify your identity
MM slash DD slash YYYY
Your Legal Marital Status
Your Biological Sex(Required)
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current age, no decimal needed
Guarantor Address
Your Current Address(Required)
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Method of Payment

How will you be paying for the visit today?
Because your injury is the result of a motor vehicle accident - health insurance does not cover the injury
Do you want to file with your automobile insurance to pay for this Motor Vehicle Accident injury?(Required)
Does Patient have motor vehicle insurance and does that insurance have Personal Injury Protection?(Required)
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)
How will you be paying for DOT exam today(Required)
How will you be paying for Pre-employment Medicine Today(Required)
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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.
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Insurance Coverage Details

Policy Holder Name(Required)
MM slash DD slash YYYY
Policy Holder Address - check if true
Policy Holder Home Address
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PRIMARY Insurance Policy Details

NOTE : WE ARE NOT in network and CAN NOT ACCEPT MEDICAID as a form of insurance
On your insurance card, what are the first 2 letters of the name of your insurance (e.g. Cigna would be Ci)
Select Other if your insurance is not listed
My NON-MEDCAID, primary insurance is not listed
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Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy
SECONDARY Policy Holder SAME AS PRIMARY INSURANCE policy holder - check if true

Secondary Insurance Policy Holder

please bring in your secondary insurance card as well
SECONDARY Policy Holder Name(Required)
MM slash DD slash YYYY
SECONDARY Policy Holder Address - check if true
SECONDARY Policy Holder Home Address
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Secondary Insurance Coverage Details

On your insurance card, what are the first 2 letters of the name of your SECONDARY insurance (e.g. Cigna would be Ci)
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
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need to add school physical wellness, DOT physical in addition to MVA, drug test
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MM slash DD slash YYYY
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= 1 is patient needs to re-sign or sign paperwork, 0 = patient is existing and paperwork is within 1 year
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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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