Online Registration Form

This Online Registration form is NOT an appointment or expedited walk-in! It is to only register digitally.

PLEASE CALL TO CONFIRM YOUR SUBMISSION!

COVID-19 TESTING:

*****NO KAISER ACCEPTED FOR COVID TESTING********

VERIFY IF YOUR INSURANCE IS ACCEPTED BY GIVING US A CALL!

IF YOU ARE HAVING SYMPTOMS, PLEASE FILL OUT THIS FORM AND CALL US WHEN YOU ARE IN THE PARKING LOT.

VERIFY TESTING CENTER INFORMATION AT 559-324-7001 IF YOU HAVE QUESTIONS OR CONCERNS.

TELEMEDICINE:

******NO HMOs, MEDI-CAL, OR KAISER FOR TELEMEDICINE. ONLY PPOs ACCEPTED.

1. Complete the form

2. YOU MUST CALL TO CONFIRM SUBMISSION.

3. Telemed wait-times are dependent on walk-in patient volume. A provider will call back same day, but there is no guaranteed wait-time.
By completing this form, the registree understands that this is not an appointment nor an official check-in. We are first come, first serve for walk-ins. We do not make same-day appointments. This is simply a means to register your information prior to your visit to expedite the paperwork process. Please sign as an agreement to the above statement*

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Name*

First NameLast Name
Date of Birth*
Format: (MM/DD/YYYY)
Sex:*

MaleFemale
Select a Reason *
Are you a new patient?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number: *
Format: XXX-XXX-XXXX
Email
Format: myname@example.com
Preferred Pharmacy*
How would you like to pay?*
Driver's License/Identification Card:

Front Side Only
Cancelof
Insurance Card: Front Side

Cancelof
Insurance Card: Back Side

Cancelof
Terms & Conditions*

I confirm the information provided is true and accurate. Any incorrect information will result in delays.

Assignment of Benefits*
In the event the patient, his/her authorized representative or the guarantor signing below, is entitled to benefits of any type arising out of any policy of insurance the patient or any other party liable for the patient those benefits are hereby assigned to Clovis Urgent Care Medical Center for application to the patient’s bill. Such payment shall discharge the insurance company of any obligations under the policy to the extend that the payment has been made according to the terms of the policy. The undersigned shall remain responsible for all charges not paid by the insurance company and/or covered by this assignment. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable for this patient is hereby assigned to Clovis Urgent Care Medical Center.
Signature*

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Patient Consent*
I hereby grant permission for the providers and staff (as directed by the providers) of Clovis Urgent Care Medical Center to perform any medical or surgical treatments as may be deemed necessary in the diagnosis and treatment of said patient.
By signing this form, you are granting consent to Clovis Urgent Care Medical Center to use and disclose your Protected Health Information (PHI) or the purpose of treatment, payment, and healthcare operations. Our Notice of Privacy Practices provides more detailed information about how we may use the disclose this protected information. Before you sign the consent, we encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our office at 559-324-7001.

You have the right to request us to restrict how we use and disclose your PHI for treatment, payment, or healthcare operations. We are not required by law to grant you request; we are bound by our agreement. If you refuse to sign and/or revoke this consent, Clovis Urgent Care Medical Center may refuse to treat you as permitted by section 164.506 of the code of Federal Regulations. You have the right to revoke this consent in writing, except to the extent we already have used, or disclosed you PHI in reliance on your consent. 


Signature*

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Financial Policy*
Thank you for choosing Clovis Urgent Care Medical Center for your health care needs. We are committed to your treatment being successful. Please understand that payment of you bill is considered a part of your treatment. Please take a moment to carefully read and sign our financial responsibility policy.

All payments will need to complete our registration forms prior to seeing the provider.

We accept Cash, Check, Visa, Mastercard, Discover, and American Express.

All co-payments, deductible, and co-insurance amounts must be paid at the time services are rendered. 

Any patient who does not cancel their appointment with a full 24-hour notice will be subject to a $25 miss appointment charge.

PPO Contacts

For contracted PPO’S, the patient is responsible for verifying that the provider is on a plan. As a courtesy, we will bill all PPO insurance for our patients; however, your medical account is your responsibility to pay. If we have not heard from your insurance company within 45 days of our billing date, we will expect payment from you.

Returned Checks

All returned checks will be subject to a $30 handling fee.

Collections 

Any amounts due that are not paid in full within 90 days will be forwarded to a collection agency. In the event of legal action should become necessary to collect any unpaid balance due for medical service rendered to you or your family, you agree to pay reasonable attorney fees, or other such cost deemed appropriate by the court. 
I have read and agree with the terms and conditions in the Financial Policy,

Signature*

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Clovis Urgent Care Financial Policy
We would like to take this time to acquaint you with the financial policies of our group. Our goal is to provide you with the highest quality care possible. In order to maintain our goal, we have highly trained staff available to help answer any questions that you may have regarding your treatment, insurance or billing issues. Please do not hesitate to ask for assistance.
Our office contracts with most Preferred Provider Organizations (PPO) as well as many Health Maintenance Organization (HMO’s). You must verify that Clovis Urgent Care is contracted with your health plan. If your health care expenses are covered by one of these plans, we require that you pay all deductible, copay and coinsurance amounts at the time of service.
We will bill your plan for the remaining balance. If we do not contract with your plan, we require payment in full at time of service. Please remember medical services are rendered directly to each patient at their request, therefore, each patient is
responsible to us for payment. By signing below, you acknowledge that failure to provide accurate insurance information or information about your insurance you will be responsible for the entire bill.
A copy of your insurance card is required at each visit. It is your responsibility to notify Clovis Urgent Care Medical Center of any changes in your coverage status. This information will be kept in your medical file. Charges billed to your insurance plan will be noted on your account until payment and/or explanation of benefits (eob) is received from the insurance company. We will bill your plan directly as a service to you, but not in substitute of your primary responsibility for payment. Charges which have not been paid by the insurance are the patient’s responsibility. All patients’ due balance will be charged to a card that is kept in a secure file. We will notify you by secure email/text message regarding balance to ensure payment is completed. Alternatively, patients may place a deposit on account toward future balances. Request for alternative methods of payment will be reviewed on an individual basis. Every effort will be made to come to an agreed upon method of payment.

There will be a $30.00 service charge on all returned checks.

Assignment and Release: I hereby authorize my insurance benefits to be paid directly to Clovis Urgent Care Medical Group and that I am financially responsible for the services that the insurance considers to be non-covered. I authorize Clovis Urgent Care Medical Center to release any information required to process my claim.

I reviewed the Financial Policy. *

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Credit Card Policy
If patient is not willing to leave a credit card on file with our office, a $5.00 billing fee will be added to your balance to offset costs.
I reviewed the credit card policy and choose to not leave a credit card on file.

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Credit Card Number:
Expiration Date:
Security Code:
Should be Empty: