• Lubbock - Patient Registration Form

  • Please Note: 

    This form will take approximately 10 minutes to complete.

    Several consent and policy forms within the intake will require your E-Signature.

    You will also be asked to take a picture of your license and insurance card.

    All information is Confidential. 

  • Section 1

    Patient Information
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  • Employment Information

  • Section 2

    Identification Information
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  • Section 3

    Insurance Information
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  • Section 4

    Guarantor Information
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  • Section 5

    Emergency Contact
  • Section 6

    Race/Ethnicity
  • Section 7

    ER Acknowledgment
  • Patient or Responsible Party to initial the following:

    I understand that I am checking into a free-standing emergency room, and this is not an urgent care. Exceptional Emergency Center is not solely a a testing center. Please initial the following page.

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  • Section 8

    Consent, Terms, and Policies
  • Consent to Use and Disclose Information 

    I agree and consent to the use and disclosure of my health information for the purpose of treatment, payment from third party payers, and other healthcare
    operations, such as the maintenance of medical records, communication of health information with other health professional who contribute to my care, and
    quality peer reviews and assessments.

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  • Section 9

    Financial Agreement and Patient Guarantee
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  • COMPLAINTS AGAINST EXCEPTIONAL EMERGENCY CENTER


    For any questions or concerns regarding Exceptional Emergency Center please contact our facility and ask for our Administrator, corporate office (469) 341 –
    7800, or the Department of State Health Services at (888) 973 – 0222.


    The physicians, nurses, and the entire staff at Exceptional Emergency Center are committed to assure your safe and reasonable care at all times. To file or voice
    a complaint, grievance about the organization, the care provided, or patient rights, and to receive a timely response without reprisal or prejudicial treatment contact:
    Belinda Boswell (469) 436 – 3110. Presentation of a complaint will not compromise your care under any circumstances. If your complaint or grievance is
    not resolved to your satisfaction, you may contact:


    Department of State Health Services Complaint Hotline
    Health Facility Compliance Group (MC 1979) 
    Department of State HealthServices
    P.O. Box 149347 Austin, TX.
    78714-9347

    Complaint Hotline

    (888) 973-0022 Texas

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  • Please sign the applicable section

  • Medicare Patients

  • I hereby agree to give my consent to Exceptional Healthcare Emergency Center that they can file my Medicare claims to my insurance company and I am liable to provide my complete and correct insurance information. I understand that I am financially responsible for the charges not covered by my insurance due to missing or incorrect information. I agree and consent to pay my Medical claim’s charges if the given information is incorrect or fail to provide in a timely manner (within 60 days).

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  • All Worker's Compensation Patients

  • Exceptional Healthcare Emergency Center is authorized to send all Medical Claims to my Worker’s Compensation Adjuster and/or Managers with my information so they can get reimbursement from Worker’s Compensation Insurance for the treatment provided and I shall provide the following correct information within a timely manner (within 60 days).


    • Worker’s Compensation carrier name

    • Claim Number

    • Injury Date

    • Adjusters name

    • Carrier Address along with Phone and Fax Number

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  • All Motor Vehicle Accident Patients

  • Exceptional Healthcare Emergency Center is authorized to send all Medical Claims to my MVA Adjuster and/or Managers with my information so they can get reimbursement from MVA Insurance and I shall provide the following correct information within a timely manner (within 60 days). 

    • MVA carrier name
    • Claim Number
    • Injury Date
    • Adjusters name
    • Carrier Address along with Phone and Fax Number
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  • All Commercial & Private Patients

  • Exceptional Healthcare Emergency Center is authorized to send all Medical Claims to my Commercial or Private insurance with my information so they can get reimbursement by commercial or private insurance and I shall provide the correct information or if my Coordination of Benefits needs to be updated I will update this information with the insurance and also provide to Exceptional Healthcare Emergency Center within a timely manner (within 60 days).

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  • HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    Exceptional Emergency Center 

    I understand, that under the Health Insurance Portability & Accountability Act of 1996 (‘HIPAA’), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: 

    • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operations such as quality assessments and physician certifications.

    I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I can contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

     
    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. 

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  • Section 10

    Coordination of Benefits
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  • Section 11

    Accident Questionnaire (if not applicable, please select no and sign at the bottom of the page)
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