Patient Paperwork Made Simple

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SPANISH-New Patient Intake

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INFORMACIÓN DEL PACIENTE

Nombre del Paciente:
(Mes/Día/Año)
Dirección:
Círculo uno:
HISTORIA MÉDICA: Detalle a continuación problemas médicos en curso, hospitalizaciones o cirugías. (Ejemplo: diabetes, hipertensión, asma, depresión, extracción de vesícula biliar, biopsias, cáncer, etc.)
Alergias a Medicamentos:
Reacción:
 
Historial Médico Familiar: Detallar a continuación (diabetes, cáncer, enfermedades cardíacas, etc.)
Historial Social: MARQUE UNO
Fumador(a):
Alcohol:
Drogas Ilícitas:
Medicamentos Actuales:
Nombre
Dosis
Cantidad de Veces Al Día
 
CONSENTIMIENTO PARA EL TRATAMIENTO
Solicito y autorizo la atención médica de PACIFIC URGENT CARE, así como de cualquier proveedor médico o designado que considere necesario o aconsejable. Esta atención puede incluir, pero no se limita a, diagnósticos rutinarios, radiología, procedimientos de laboratorio y administración de algunos medicamentos.
FIRMA DEL PACIENTE O REPRESENTANTE AUTORIZADO
Fecha:
SEGURO PRIVADO, CESIÓN DE BENEFICIOS MÉDICOS
Por la presente, cedo, transfiero y asigno a PACIFIC URGENT CARE CENTER todos mis derechos, títulos e intereses en los beneficios de reembolso médico bajo mi póliza de seguro para cualquier servicio proporcionado por PACIFIC URGENT CARE CENTER. Entiendo que soy financieramente responsable de cualquier saldo que no esté cubierto por mi proveedor de seguros.
FIRMA DEL PACIENTE O REPRESENTANTE AUTORIZADO
Fecha:
AUTORIZACIÓN DE COMUNICACIONES
PACIFIC URGENT CARE CENTER, sus médicos y personal, están autorizados a utilizar sistemas de mensajes por teléfono o correo electrónico para facilitar la comunicación conmigo o con mi representante autorizado, en relación con mi tratamiento, citas, arreglos financieros y en respuesta a cualquier solicitud que haya iniciado.
FIRMA DEL PACIENTE O REPRESENTANTE AUTORIZADO
Fecha:
MEDICARE, CESIÓN DE BENEFICIOS MÉDICOS (SI APLICA)
Solicito que el pago de los beneficios autorizados por Medicare se realice bien a mí o en mi nombre a PACIFIC URGENT CARE CENTER por cualquier servicio proporcionado para mí por el médico o proveedor. Autorizo a cualquier poseedor de información médica sobre mí a divulgar a PACIFIC URGENT CARE CENTER y sus agentes cualquier información necesaria para determinar estos beneficios o los beneficios pagaderos por los servicios relacionados.
FIRMA DEL PACIENTE O REPRESENTANTE AUTORIZADO
Fecha:
AUTORIZACIÓN PARA USAR Y/O DIVULGAR INFORMACIÓN DE SALUD
PACIFIC URGENT CARE CENTER, sus médicos y personal, están autorizados a COMPARTIR INFORMACIÓN y proporcionar copias de mis registros médicos completos, incluyendo todos los informes escritos y orales, evaluaciones sustantivas de progreso, historia, diagnóstico, pronóstico, curso del tratamiento, informes y asistencia y cumplimiento respecto a toda atención o tratamiento, incluyendo toda la información confidencial relacionada con VIH y SIDA, registros de salud mental, registros de tratamiento de drogas y alcohol, registros de asesoramiento por agresión sexual y abuso sexual a mis compañías de seguros, médicos, instalaciones de tratamiento y mi empleador en el caso de Compensación de Trabajadores, Y A LAS PERSONAS SIGUIENTES SI SE DESEA:
Nombre:
Relación:
 
FIRMA DEL PACIENTE O REPRESENTANTE AUTORIZADO
Fecha:
AVISO DE PRÁCTICAS DE PRIVACIDAD (HIPAA)
Estamos comprometidos con mantener la confidencialidad de su información de salud y cumplimos plenamente con HIPAA. Al firmar este formulario, usted reconoce su comprensión de nuestro cumplimiento con HIPAA y nuestro compromiso de proteger su privacidad.
FIRMA DEL PACIENTE O REPRESENTANTE AUTORIZADO
Fecha:
HE LEÍDO Y COMPRENDIDO LAS ASIGNACIONES Y AUTORIZACIONES ANTERIORES PARA USAR/DIVULGAR INFORMACIÓN DE SALUD SOBRE EL PACIENTE NOMBRADO TAL COMO SE DESCRIBE. ESTAS ASIGNACIONES/AUTORIZACIONES PERMANECERÁN VIGENTES HASTA QUE SEAN REVOCADAS POR MÍ POR ESCRITO.
UNA COPIA DE CUALQUIERA O TODAS LAS FIRMAS ANTERIORES ES TAN VÁLIDA COMO LOS ORIGINALES

CESIÓN DE BENEFICIOS Y GARANTÍA DE PAGO


PACIFIC URGENT CARE CENTER tiene contratos con ciertos seguros PPO y HMO y Medicare. Si su seguro tiene un copago, el copago siempre debe pagarse en la fecha del servicio. No aceptamos cheques como forma de pago para los copagos. Si estamos contratados con su aseguradora y no podemos verificar sus beneficios de seguro en la fecha del servicio, le cobraremos $40 como garantía y proporcionaremos un ajuste con nuestra oficina de facturación una vez que se pueda verificar el seguro. Si la facturación no puede verificar el seguro, si se indica que está inactivo en la fecha del servicio, o si no está dentro de las redes con las que estamos contratados, usted será responsable por el costo completo de la visita y los servicios prestados.

Si no estamos contratados con su seguro y aún desea una consulta con el médico, la consulta será un gasto de $95 a pagar de su propio bolsillo. Con todas las consultas de pago de su propio bolsillo, el pago debe hacerse en el momento del servicio. Cualquier otro servicio proporcionado o solicitado durante la consulta tendrá un costo adicional, pero queda a discreción del paciente.

Todo trabajo de laboratorio, pruebas diagnósticas o imágenes ordenadas por el médico serán facturados como responsabilidad del paciente si es de pago de su propio bolsillo o a su aseguradora por las instalaciones de prestación de servicios que PACIFIC URGENT CARE CENTER utiliza para estos servicios.

Utilizamos el Programa de Monitoreo de Drogas con Receta del Departamento de Justicia de California (CURES) para identificar el historial de dispensación de medicamentos con receta. Nuestros médicos no recetarán medicamentos controlados si se han recetado medicamentos controlados por médicos fuera de PACIFIC URGENT CARE CENTER de manera continua y regular.

Usted será responsable de todos los cargos estándar de la consulta para la evaluación. Si no paga ninguna reclamación de seguro presentada por PACIFIC URGENT CARE CENTER, su cuenta será enviada a una agencia de cobranzas, y se añadirá un 25% adicional al saldo. Habrá una tarifa administrativa de $30 para todas las autorizaciones retroactivas.

Entiendo que soy responsable de pagar la parte de mi factura no cubierta por compañías de seguros, agencias gubernamentales y terceros pagadores. Autorizo a PACIFIC URGENT CARE CENTER a procesar cargos en mi(s) tarjeta(s) de crédito, tarjeta(s) de débito y/o cuenta(s) bancaria(s) para los cargos de la visita actual, cargos pasados o saldos futuros de esta visita que no sean pagados por terceros como compañías de seguros. En consideración a los servicios prestados, acepto pagar a PACIFIC URGENT CARE CENTER de acuerdo con las tarifas y términos regulares de PACIFIC URGENT CARE CENTER.

Si recibo un estado de cuenta, además acepto pagar la cuenta en su totalidad al recibirlo y bajo las condiciones del estado de cuenta, a menos que se hayan realizado otros arreglos de pago previamente. Autorizo que dichos pagos se apliquen a cualquier saldo impago de PACIFIC URGENT CARE CENTER por el cual soy responsable.

En consideración a los servicios proporcionados por PACIFIC URGENT CARE CENTER, por la presente asigno y transfiero a PACIFIC URGENT CARE CENTER todos los derechos que tengo contra compañías de seguros, agencias gubernamentales o terceros pagadores, para el pago de cargos por servicios proporcionados por PACIFIC URGENT CARE CENTER a mí o a mis dependientes.
AL FIRMAR A CONTINUACIÓN, RECONOZCO QUE HE LEÍDO Y COMPRENDIDO LA INFORMACIÓN ANTERIOR.
UNA COPIA DE CUALQUIERA O TODAS LAS FIRMAS ANTERIORES ES TAN VÁLIDA COMO LOS ORIGINALES.

PPD Skin Test Consent

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I have read and answered the questions above. I hereby consent to have PPD test - which screens for Tuberculosis, be done on me and I shall return within 48-72 hours to have the rest read.

Section Below is for Office Use Only

Pacific Urgent Care Center

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Patient Information

Patient Name*
MM slash DD slash YYYY
Address*
Max. file size: 1 GB.

Social History: MARK ONE

CONSENT FOR TREATMENT


I request and authorize medical care from PACIFIC URGENT CARE, as a medical provider or designees that may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology, laboratory procedures, and some medication administration.
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PRIVATE INSURANCE, ASSIGNMENT OF MEDICAL BENEFITS


I hereby assign transfer and set over to PACIFIC URGENT CARE CENTER all of my rights, title and interest to my medical reimbursement benefits under my insurance policy for any services furnished to me by PACIFIC URGENT CARE CENTER. I understand I am financially responsible for any balance that is not covered by my insurance provider.
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*MEDICARE, ASSIGNMENT OF MEDICAL BENEFITS (IF APPLICABLE)


I request that payment of authorized Medicare benefits be made either to me or on my behalf to PACIFIC URGENT CARE CENTER for any services furnished for me by physician or supplier. I authorize any holder of medical information about me to release to PACIFIC URGENT CARE CENTER and its agents any information needed to determine these benefits or the benefits payable for related services.
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COMMUNICATIONS AUTHORIZATION


PACIFIC URGENT CARE CENTER, its physicians, and staff, are authorized to use telephone or email message systems to aid communication with me, or my authorized representative, regarding my treatment, appointments, financial arrangements, and in response to any request I have initiated.
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MM slash DD slash YYYY

NOTICE OF PRIVACY PRACTICES (HIPAA)


We are committed to maintaining the confidentiality of your health information and are fully HIPAA compliant. By signing this form, you acknowledge your understanding of our HIPAA compliance and our commitment to protecting your privacy.
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AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION (OPTIONAL)


PACIFIC URGENT CARE CENTER, its physicians and staff, are authorized to SHARE INFORMATION and provide copies of my entire medical records, including all written and oral reports, substantive evaluations of progress, history, diagnosis, prognosis, course of treatment, reports, and attendance and compliance with respect to all care or treatment, including all confidential HIV and AIDS related information, mental health records, drug and alcohol, abuse treatment records, sexual assault and sexual abuse counseling records to my insurance companies, doctors, treating facilities, and my employer in the case of Worker’s Compensation, AND THE FOLLOWING PERSONS IF DESIRED:
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I HAVE READ AND UNDERSTAND THE ABOVE ASSIGNMENTS AND AUTHORIZATIONS TO USE/DISCLOSE HEALTH INFORMATION ABOUT THE NAMED PATIENT AS DESCRIBED. THESE ASSIGNMENTS/AUTHORIZATIONS REMAIN IN AFFECT UNTIL REVOKED BY ME IN WRITING.
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A copy of any or all above signatures is as valid as the originals
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ASSIGNMENT OF BENEFITS & PAYMENT GUARANTEE


PACIFIC URGENT CARE CENTER is contracted with certain PPO and HMO insurances and Medicare. If your insurance has a copay, the copay is always due on the date of service. We do not accept checks as a form of payment for copays. If we are contracted with your insurance carrier and are unable to verify your insurance benefits on the date of service, we will charge you $40 as collateral and provide an adjustment with our billing office once the insurance is able to be verified. If billing is unable to verify the insurance, if it states that it is inactive for the date of service, or it is not within the networks we are contracted with, you will be held responsible for the full visit and any services rendered.

If we are not contracted with your insurance and would still like to have a doctor consultation, the doctor consultation will be an out-of-pocket expense of $95. With all out-of-pocket consultations, the payment is due at the time of service. Any other services provided or requested during the consultation will be at an additional cost, but up to the patient’s discretion.

All lab work, diagnostic testing services, or imaging ordered by the physician will be billed as the patient’s responsibility if out-of-pocket or to your insurance carrier by the rendering facilities that PACIFIC URGENT CARE CENTER uses for these services.

We utilize the California Department of Justice Bureau of Narcotic Prescription Drug Monitoring Program (CURES) to identify prescription drug dispensing history. Our physicians will not prescribe controlled medications if any controlled medications have been prescribed by physicians outside PACIFIC URGENT CARE CENTER on an ongoing and regular basis.

You will be responsible for all standard office visit charges for the evaluation. If you fail to pay any insurance claims submitted by PACIFIC URGENT CARE CENTER, your account will be placed with a collection agency, an additional 25% will be added to the balance. There will be a $30 clerical fee for all retro authorizations.

I understand that I am responsible for and will pay the portion of my bill not covered by insurance companies, governmental agencies, and third-party payers. I am authorizing PACIFIC URGENT CARE CENTER to process charges on my credit card (s), debit card (s), and/or bank account (s) for the current visit charges, past charges, or for future balances on this visit that are not paid by any third-party such as insurance carriers or companies. In consideration of services to be provided, I agree to pay PACIFIC URGENT CARE CENTER in accordance with the regular rates and terms of PACIFIC URGENT CARE CENTER.

If I receive a billing statement, I further agree to pay the account in full upon receipt and conditions of my billing statement unless other payment arrangements are made first. I authorize said payments to be applied to any unpaid PACIFIC URGENT CARE CENTER balance for which I am responsible.

In consideration of services being provided by PACIFIC URGENT CARE CENTER, I hereby assign and transfer to PACIFIC URGENT CARE CENTER any and all rights, which I have against insurance companies, governmental agencies, or third-party payers, for payment of charges for services provided by PACIFIC URGENT CARE CENTER to me or my dependents.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.
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A copy of any or all above signatures is as valid as the originals
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Max. file size: 1 GB.
Max. file size: 1 GB.

TB Risk Assessment

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California School Employee Tuberculosis (TB)

Risk Assessment Questionnaire

(for pre-K, K-12 schools and community college employees, volunteers and contractors)

  • Use of this questionnaire is required by California Education Code sections 49406 and 87408.6, and Health and Safety Code sections 1597.055 and 121525-121555.
  • The purpose of this tool is to identify adults with infectious tuberculosis (TB) to prevent them from spreading disease.
  • Do not repeat testing unless there are new risk factors since the last negative test.
  • Do not treat for latent TB infection (LTBI) until active TB disease has been excluded: For individuals with signs or symptoms of TB disease or abnormal chest x-ray consistent with TB disease, evaluate for active TB disease with a chest x-ray, symptom screen, and if indicated, sputum AFB smears, cultures and nucleic acid amplification testing. A negative tuberculin skin test (TST) or interferon gamma release assay (IGRA) does not rule out active TB disease.
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History of Tuberculosis Disease or Infection (Check appropriate box below)
TB testing is recommended if any of the 3 boxes below are checked

Treat for LTBI if TB test result is positive and active TB disease is ruled out

The law requires that a health care provider administer this questionnaire. A health care provider, as defined for this purpose, is any organization, facility, institution or person licensed, certified or otherwise authorized or permitted by state law to deliver or furnish health services. A Certificate of Completion should be completed after screening is completed (page 3).

Certificate of Completion Tuberculosis Risk Assessment and/or Examination

To satisfy job-related requirements in the California Education Code, Sections 49406 and 87408.6 and the California Health and Safety Code, Sections 1597.055, 121525, 121545 and 121555.

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The above named patient has submitted to a tuberculosis risk assessment. The patient does not have risk factors, or if tuberculosis risk factors were identified, the patient has been examined and determined to be free of infectious tuberculosis.
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Please print, place label or stamp with Health Care Provider Name and Address (include Number, Street, City, State, and Zip Code):

Pacific Urgent Care Center – Sports Physical

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Patient Information

Patient Name*
MM slash DD slash YYYY
Address*

COMMUNICATIONS AND PAYMENTAUTHORIZATION


I authorize PACIFIC URGENT CARE CENTER, its physicians, and staff, to use telephone or email message systems to aid communication with me, or my authorized representative, regarding my treatment, appointments, financial arrangements, and in response to any request I have initiated.

I authorize PACIFIC URGENT CARE CENTER to process charges on my credit card (s), debit card (s), bank account (s), and/or cash payment (s) for the current visit charges. I understand that I am electing to go out-of-pocket for the sports physicals and will not be provided documentation to submit for reimbursement from my insurance.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.

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Pacific Urgent Center

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CONSENT FORM FOR TREATMENT OF A MINOR


Consent for Treatment of a Minor: Treatment of minors requires a team effort by the medical care provider(s) and the minor's parent of guardian. The parent or guardian's responsibility includes supporting the medical directives given by the medical provider. The medical provider's role includes ensuring that the parent or guardian is aware of and concurs with the treatment their child and charges their child receives.

Treating minors in the clinic: It is the policy of PACIFIC URGENT CARE CENTER that all minors seeking treatment be accompanied by a parent/legal guardian for the first visit. After the initial appointment, a minor maybe seen at the clinic for treatment without the parent/legal guardian present if this consent form is filled out and maintained in the minor's medical record.

Consent for Medical and Surgical Treatments: This form authorizes PACIFIC URGENT CARE CENTER to evaluate and treat your child. This permission includes treatment, minor surgical procedures, injections, immunizations and the writing of all prescriptions.

I authorize and give consent to the PACIFIC URGENT CARE & FAMILY MEDICINE for medical evaluation and treatment of my child if a parent/legal guardian is not present. THIS AUTHORIZATION MUST BE COMPLETED ANNUALLY UNTIL THE MINOR IS 18 YEARS OF AGE.
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(Starting Date)
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(Up to one year)