Patient Intake Form

PATIENT INFORMATION

First Name *

Last Name *

M.I.

Previous Name: (If Applicable)

Home Phone

Cell Phone: *

Work Phone

Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages

Please Select Only One Option

Voice

Text

If Voice, Please Select Preferred Number

Home

Cell

Work

Family Physician or Pediatrician

Date of Birth

Sex

Male

Female

Marital Status

Social Security

Employer Name

Emergency Contact Name

Emergency Contact Phone

Relationship to Patient

ADDITIONAL INFORMATION & RESPONSIBLE PARTY

Responsible Party- If the Patient is a minor (under Age of 18), the Parent or guardian bringing the patient in will be listed as the guarantor

First Name

Last Name

Date of Birth

Social Security#

Phone

INSURANCE INFORMATION

Enter your paI certify that I read and agree to Premier Acute Care (PACS) payment policy. I am eligible for the Insurance Indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to PACS all money to which I am entitled for medical expenses related to the services performed from time to time by PACS. I authorize PACS to release any medical information to my insurance carrier or third-party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency acquiring a 30% interest charge to your account. A $40.00 returned check fee will be charged for checks returned due to insufficient funds. I choose to receive communications from PACS by text or e-mail at the number or e-mail address stated above, including but not limited to communications about appointments, treatment, and payment. I understand that such e-mails and texts may not be secure and there is a risk that they may be read a third party. MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to PACS. I authorize ant holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.ragraph text here...

I have reviewed a copy of Premier Acute Care (PACS) Privacy Notice. (Initials)

Signature of Responsible Party

Use your mouse or finger to sign in the box below.

Date

Printed Name of Responsible Party

Date

MEDICAL RELEASE OF INFORMATION (Hippa Release Form)

Name

Date Of Birth

RELEASE OF INFORMATION

You expressly consent and agree that, in order to discuss or services your account(s)("the Accounts") or to collect amounts you may owe, PACS urgent Care, and officers, agents, affiliates, employees, and affiliated or associated service providers and third-party debt collection agency associated therewith (collectively, "WE") may contact you by telephone at any telephone number associated with Accounts including wireless telephone numbers, which could result in charges to you. You expressly consent and agree that we may also contact you by sending text messages, automatic dialing methods, system, or devices, and pre-recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile telephone numbers, regardless of whether you incur charge results.

I authorize the information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:

Spouse

Child(ren)

Parents

Other

Information is not to be released to anyone

This Release of Information will remain in effect until terminated by me in writing.

Preferred Contact Method

Please Call

My Home

My Work

My Mobile

If unable to reach me

You may leave a detailed message

Please leave a message asking me to return your call

Best time to reach me is:

The above information is true the to best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize PACS Urgent Care to release any information required to process my claims.

Patient/ Parent or Guardian Signature

Use your mouse or finger to sign in the box below.

Date

Premier Acute Care Services

Premier Acute Care Services

PATIENT INFORMATION

ADDITIONAL INFORMATION & RESPONSIBLE PARTY

ADDITIONAL INFORMATION (PLEASE FILL OUT ALL SECTIONS BELOW)

INSURANCE INFORMATION

Primary Medical Insurance

Secondary Medical Insurance

INSURANCE INFORMATION

MEDICAL RELEASE OF INFORMATION (Hippa Release Form)

RELEASE OF INFORMATION

Preferred Contact Method

Premier Acute Care Services

Premier Acute Care Services