PATIENT INFORMATION and Return to the Front Desk to Retrieve Alternate Paperwork

*Is this a worker’s compensation claim?If yes, please stop filling out this form PATIENT INFORMATION and return to the front desk to retrieve alternate paperwork. M Patient Name (First, Middle, Last) Date of Birth Sex F Name of parent/responsible party, if minor Address City State Zip Cell phone Home phone Work phone Email Primary insurance company Name of primary insurance holder Primary insurance holder’s DOB Secondary insurance company Name of secondary insurance holder Secondary insurance holder’s DOB Preferred pharmacy EMERGENCY CONTACT INFORMATION Name Relationship Address City State Zip Phone (Day) Phone (Evening) Cell DEMOGRAPHIC INFORMATION (Requested by the Federal Government) RACE: American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Prefer not to say ETHNICITY: Hispanic or Latino Not Hispanic or Latino Prefer not to say PREFERRED LANGUAGE: English Spanish Other HOW DID YOU HEAR ABOUT BESTCARE NOW URGENT CARE? Drove by the building Recommendation from a friend Google search Other internet search HOA/School/Local Promotion Facebook Newspaper ad Billboard Community Event Other WOULD YOU LIKE TO HEAR MORE ABOUT ANY OF THESE BESTCARE NOW SERVICES TODAY? BestYou Weight Loss Program BestHealth Membership Program Flu Shot Physical Occupational Medicine services for your company PATIENT HISTORY Patient Name (First, Middle, Last) Patient Date of Birth ALLERGIES: Medicine Other CURRENT MEDICATIONS (Include non-prescription drugs) 1. 3. 5. 7. 2. 4. 6. 8. PLEASE MAKE AN (X) BY ANY OF THESE CONDITIONS YOU MAY HAVE OR HAVE HAD IN THE PAST: Heart disease Kidney, bladder or prostate disease Bleeding tendency Muscle disease High blood pressure Joint replacement Stroke Mental health problems High cholesterol 13 Liver disease Seizures Depression Lung disease Bowel disease Nerve impairment Chronic skin disease Diabetes Cancer (past or present) Cervical spine disorder Sleep Apnea Hypoglycemia (low Glucose) Anemia or other blood disease Lumbar spine disorder Other Thyroid disease Blood clots Severe headaches Tuberculosis/TB ORTHOPEDIC OR OTHER MAJOR SURGERIES Approx Date Surgery Approx Date Surgery Approx Date Surgery Approx Date Surgery PERSONAL HABITS Do you drink caffelnated beverages (coffee, tea, soda)?... Yes No If Yes, Daily Intake? Do you drink alcoholic beverages?.................................. Yes No If Yes, Drinks per Day Week Month Do you smoke or chew tobacco?..................................... Yes No If Yes, per day, years of use If no, any prior nicotine use years of use SPECIAL CONSIDERATIONS Legally Blind Pregnant Need Handicap Facilities Hearing impaired Attempting Pregnancy None of the Above PATIENT ACKNOWLEDGEMENTS Consent to Treatment: I voluntarily consent to receive medical and health care services provided by BestCare Now, LLC physicians, employees and such associates, assistants, and other health care providers as deemed necessary. I understand that such services may include diagnostic procedures, examinations, and treatment. I acknowledge that no warranty or guarantee has been made to me as a result or cure. I acknowledge that this facility may use health information exchange systems to electronically transmit, receive, and/or access my medical information which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history, and other health care information. I understand that this Consent to Treatment/Health Care Agreement will be valid and remain in effect only for my visit today and the services provided during this visit. Release of Medical Information: I acknowledge that “protected health information” pertains to my diagnosis and/or treatment at BestCare Now, LLC, including but not limited to, information concerning mental illness (except for psychotherapy notes), use of alcohol or drugs, or communicable diseases. I acknowledge that the “Notice of Privacy Practices” provides information about how this facility may use and/or disclose protected health information about me for treatment, payment, health care operations and as otherwise allowed by law. I understand that BestCare Now, LLC cannot be responsible for use or re-disclosure of information by third-parties. Financial Responsibility and Assignment of Benefits:In consideration for health care services, I hereby assign to BestCare Now, LLC physicians and providers my right, title, and interest in all insurance, Medicare/Medicaid, or other third-party payer benefits for medical or healthcare services otherwise payable to me. I also authorize direct payments to be made by Medicare/Medicaid and/ or my insurance company or other third-party payer, up to the total amount of my medical and health care charges to BestCare Now physicians. I certify that the information I have provided in connection with any application for payment by third-party payers, including Medicare/Medicaid, is correct. I agree to pay all charges for medical and health care services not covered by, or which exceed, the amount estimated to be paid, or actually paid by Medicare/Medicaid, my insurance company, or other third-party payer, and agree to payment as requested by BestCare Now, LLC. Notice of Privacy Practices: I have received a copy of the Notice of Privacy Practices ________ (Patient’s initials). _______________________________________ __________________________________ ___________ Signature of patient / Legal representative Printed name Date HIPAA CONSENT FOR RELEASE OF MEDICAL INFORMATION I, ________________________________________ (patient name), give my permission for BestCare Now Urgent Care to disclose private medical information to __________________________ (name of recipient) if I am unavailable or incapacitated for any reason. This third party is my _____________________ (relationship to patient). This includes / excludes (circle one) HIV-AIDS information. This agreement will remain effective until I notify BestCare Now in writing. _______________________________________ __________________________________ ___________ Signature of patient / Legal representative Printed name Date.

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