Summit Online Registration

Clinic Location *

Patient Name *

First Name Last Name

Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Patient Date Of Birth *

Date

Phone Number *

Area Code Phone Number

Email *

example@example.com

Reason for Visit *

Emergency Contact Name *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

Preferred Pharmacy (Short description so we can look it up for you. i.e. Kroger on Lower Fayette) *

Drivers License (Front) *

Do you have insurance? (No indicates Self Pay) *

Yes No

Guarantor (Insurance Owner) *

First Name Last Name

Guarantor Date of Birth *

Date

Insurance Card (Front) *

Insurance Card (Back) *

Consent for Treatment : I consent to the care and treatment by Summit Urgent Care. The treatment may include but is not restricted to medications, anesthesia, surgical and invasive procedures, lab, x-ray, or other studies that may be helpful in the performance of the patient's care.

Exposure to Disease : I understand that if my physician(s), or any person employed by or under the direction and control of my physician(s), is directly exposed to my body fluids in any manner which may, according to the current guidelines for the Center for Disease Control, transmit the human immunodeficiency virus (HIV) or Hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or Hepatitis B or C viruses. I further understand that by law I will have deemed to have consented to the release of the test results to the person who is exposed to my body fluids.

Medicare and Medicaid : We are not contracted with any of the government insurance programs. Therefore, we do not have the required assigned number that is necessary to file for Medicare and Medicaid insurance plans. This means that we are not able to treat anyone on these plans, even on a cash-paying basis. By initialing in the space below, you are attesting to the fact that you are NOT enrolled in any Medicare or Medicaid plan.

We are committed to meeting your healthcare needs and keeping your insurance and other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner for all our patients, we ask that you adhere to our practices financial policy. By signing below, you are agreeing to its terms.

I am ultimately responsible for payment of charges for services I receive from this practice, including those convered by my insurance. As a convenience, this practice will submit claims for reimbursement with my insurance provider; however, all payment responsibility is ultimately mine.
Some immediate payment may be expected at the time of service. This may include a copay, coinsurance, deductible and/or additional payment if this practice determines that the cost of my ivisit today will not be reimbursed by my insurance provider.

I understand that my signature and card information will be maintained on file digitally and secured via tokenization for future use by the practice. My card will never be processed without prior authorization by cardholder.
I authorize the above practice and/or its designated provider to send electronic account statements and invoices to my email address on file. I undersatnd that it is my responsibility to maintain a current email address on file and that I will not receive a mailed copy of any electronic statement.

This authorization will remain in effect until I provide written notice of cancellation to the practice. Authorization for services already rendered cannot be cancelled or refunded. I agree to notify the practice in writing of any changes in my payment or other information.

I have read, understand, and agree to the Summit Urgent Care, LLC policy stated above.

Date *

Date

Signature *

Clear

Signature

Patient Registration

Consent and Policy