First Name * Middle Name Last Name * Social Security Number Date of Birth Age * Sex MaleFemale Martial Status MSDWC Street City State Zip Phone Employer Occupation Driver's License Number Work Street Work City Work State Work Zip Work Phone
First Name Middle Name Last Name Social Security Number Date of Birth Age Sex MaleFemale Martial Status MSDWC Street City State Zip Phone Employer Occupation Driver's License Number Work Street Work City Work State Work Zip Work Phone
Company Name Address Subscribers Name Date of Birth Policy Number Group Number
Person to Contact In an Emergency Home Address Home Phone Work Phone Name of Relative Not Living With You Address Home Phone Work Phone
Patient Signature
Upload Insurance Card (front and back)
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I,
hereby certify that I am eligible for
Effective through
I have chosen Raincross Urgent Care to be my Medical Provider.
I understand that if the above is not true or if I am not eligible under the terms of my employers Medical and Hospital Subscriber Agreement, i am liable for all charges for services rendered. Also if the above is not true, I agree to pay in full for all services within 30 days of receiving a bill from Raincross Urgent Care.
Signature of Patient (or Guardian)
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is the responsibility of the patient to pay any deductible amount, co-pay, co-insurance, or any other balance not paid for by insurance.
IN ORDER TO CONTROL THE COST OF BILLING, WE REQUEST THAT THE TOTAL CHARGES FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT.
If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney’s fees and costs of collection.
To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosures of portions of the patient’s record.
I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled including MediCare, private insurance, and other health plans to: Raincross Medical Group, Inc.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.
ADDITIONAL CHARGES MAY BE BILLED FROM OTHER PROVIDERS FOR SERVICES RENDERED.
Date
Patient Name
Date of Birth
Relationship to Patient
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You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or with the policies and procedures of our office. We will not retailate against you for filing a complaint.
For more information about HIPAA or to file a complaint you may contact:
The U.S. Dept of Health & Human Services Office of Civil Rights 200 Independence Ave, S.W. Washington, D.C. 20201 (202) 619-0257 or 1-877-696-6775
Do not release my information to anyone except as detailed in the HIPAA Notice of Privacy Practices
Or,
I give my permission to disclose medical information to the following:
Recipient 1 Name Relationship Contact Phone Recipient 2 Name Relationship Contact Phone Recipient 3 Name Relationship Contact Phone Recipient 4 Name Relationship Contact Phone
I have read and understand the HIPAA Notice of Privacy Practices and Patient’s Rights and Responsibilities as stated above. These policies may change from time to time. I may request a current copy of this form at any time. I also agree to release (or not release) information as per the Authorization to Release Information Section:
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Phone (951) 774-2860