Patients Covid-19 testing form | Haven Elite Urgent Care

Name *

First

Last

Date of Birth *

Sex *

M
F

Marital Status *

Single
Married
Window
Divorced

Cell Phone Number *

Home Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email

Preferred Language

Emergency Contact *

First

Last

Emergency contact phone number

Emergency Contact Relationship

How did you hear about us?

Pharmacy Information

Pharmacy Name *

Pharmacy Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Doctor Name

Primary Doctor Address

Address Line 1

Address Line 2

City

State

Zip Code

Authorization & Signatures

How will you be paying for today's bill? *

Self-Pay
Insurance -I will present my insurance card and Photo ID

Insurance Card -Front and Back *

Click or drag files to this area to upload. You can upload up to 2 files.

Take a Picture of your Insurance Card (Front and Back) and Upload it here.

Photo Identification -Front only *

Click or drag a file to this area to upload.

Take a Picture of your Drivers License, State ID, or Valid Photo ID.

Consent for Medical Treatment: *

I give permission to Haven Elite Urgent Care to perform the following services that the physicians and other non physician providers and assistants may deem to be necessary: (a) medical, surgical, and diagnostic processes, treatments, and procedures; (b) administration of injections, medications, and immunizations; and (c) completion of medically appropriate tests for communicable and other diseases.

Date: *

Narcotics Prescription Policy: *

Prescriptions for opioids will be written only in situations in which the provider considers them absolutely necessary and duration typically will be three days. Before prescribing any controlled substance to you, we may request and review information from California's Prescription Drug Monitoring Program, CURES 2.0, regarding your prior receipt of controlled substances. There may be additional requirements by the provider for patients receiving narcotics prescriptions.

Date: *

Financial Policy: *

Unless you are here for employer paid services, you will be responsible for either full payment or payment as indicated by your insurance plan. If Haven Elite Urgent Care has a contract with your insurance company, we will file today's charges with that insurance company. You will be responsible for your co-payment and/or deductible, and the cost of any services not covered by insurance. You may receive a bill from Haven Elite Urgent Care for any unpaid balance. Accounts not paid in a timely manner may be subject to interest, late fees and additional collection costs.

Date: *

Financial Responsibility *

I understand that I am responsible for securing any referral/pre-authorization and that I am financially responsible for all charges not covered by insurance.

Initials: *

Release of Medical Records, Assignment of Benefits, Financial Responsibility: *

Haven Elite Urgent Care will submit claims to my insurance carrier as well as medical records needed to evaluate the claims for payment. I further assign payment of benefits, otherwise payable to me, to be made payable to Haven Elite Urgent Care. I understand that I am financially responsible for all charges not covered by my insurance.

Date *

Notice of Privacy Practices: *

Your signature below indicate that you have been made aware of Haven Elite Urgent Care's Notice of Privacy Practices (NOPP) on the date indicated. You can obtain a copy at the link below and on our website.

To obtain a copy for your records: http://havenelite.com/wp-content/uploads/2020/12/Haven-Elite-UC-Notice-of-Privacy-Practice.pdf

Date *

Telephone Contact *

You consent and agree that you may be contacted by telephone at any telephone number associated with your account. You expressly consent and agree that we may also contact you by sending text messages, emails, using any e-mail address you provide us.

Date *

If you do not have insurance:

If you do not have insurance coverage or Haven Elite Urgent Care does not have a contract with your insurance company, you will be required to pay in full for your visit today.

Initials:

Pharmacy Information

Authorization & Signatures

HELPFUL LINKS:

HOURS

ADDRESS