4646 BROCKTON AVENUE SUITE 101, RIVERSIDE, CA 92506
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
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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
I voluntarily consent to such care including routine procedures and other treatment by Raincross Medical Group, Inc. professionals and their assistants, appointees, or consultants as is necessary in their judgement.
I am aware that the practices of medicine, surgery and other health disciplines do not constitute exact sciences and I acknowledge that no guarantees have been made to me as to the result of the treatments or examination by Raincross Medical Group, Inc.
I understand that for certain procedures deemed necessary by my physician I will be required to sign a Special Consent Form.
I understand that Raincross Medical Group, Inc. shall not be responsible or liable for the loss of damage to any personal property.
I authorize the release by telephone, mail, fax, computer or personal delivery to any party responsible for my care, such as information from my records as is required in order for the clinic and all entities providing services to obtain payment. This includes records of alcohol and drug abuse and/or treatment, records of psychological services and social services, including communications made by the patient to a physician, social worker, or psychologist. This authorization shall be effective only so long as necessary to obtain payment or reimbursement is received.
I recognize that there are certain restrictions inherent in telemedicine services that lend to additional risk. Telemedicine services are done remotely, meaning that the doctor and the patient are in 2 physically different places. This means that the healthcare provider is not able to see you in person, vital signs may not be performed, it is not possible to perform a physical exam, it may be more difficult to evaluate medications that you are on, and labs that are normally done in clinic such as a urinalysis and blood glucose may not be performed. The inability to perform these services may lead to diagnostic inaccuracy and changes in the treatment plan that may be inferior to a plan that was chosen if you were seen in person. This may put you at increased health risk if you choose to participate in this type of visit. Additionally, participation in a telehealth visit may impact whether your health insurance company will pay for the visit. Telehealth visits are billed to the insurance company at the same rate as in person visits. Please weigh these risks against the convenience of not having to come to the clinic, protecting yourself against acquiring an infection when you come in to the clinic and the improved access that you enjoy to the healthcare provider. By choosing to participate in the telehealth visit you are consenting that you have weighed these risks and benefits and you have accepted the risks.
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 PracticesOr,
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
To receive service in a reasonable period of time.
To receive medically necessary service.
To be treated with respect and courtesy.
To receive all available information about your care and treatment, including risks and options.
To have your medical coverage explained to you.
To participate in treatment decisions.
To refuse treatment.
To receive impartial access to treatment.
To receive a second opinion regarding any treatment plan.
To review or to receive a copy of your medical record subject to legal restrictions and reasonable copying charges.
To request review of your medical records by the physician, and to request corrections if necessary.
To be given information on how to file a complaint/grievance.
To formulate an advance directive if you have a life threatening illness or injury.
Having appropriate identification, insurance membership cards, coverage stickers, etc. at the time of the appointment.
Keeping appointments or contacting this office in advance to cancel an appointment.
Fulfilling financial obligations at the time of service such as deductible or co-pay fees.
Providing complete and accurate information.
Following the health plan you and the physician agree on.
Being considerate of others.
Providing legal documentation of guardianship or a minor being treated.
Providing a list of person who may receive medical information about you, on your behalf, in an emergency.
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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