*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

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 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:

 disease  , bladder or disease  Bleeding tendency  Muscle disease  High blood pressure  replacement  Stroke  Mental health problems  High cholesterol 13  disease  Seizures  Depression  disease  Bowel disease  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  disease  Blood clots  Severe headaches  Tuberculosis/TB

ORTHOPEDIC OR OTHER MAJOR

Approx Date 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 , 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