Direct Primary Care Patient Inquiry Form

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthdate (We can only treat patients 18 and older)*

Date

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

DateTime

Do you currently have Health Insurance? (You do not need to have health insurance to become a patient of Urick Internal Medicine). Please pick the one that BEST describes you.

*** Please note, that since Dr Urick is not enrolled with Medicare or Medicaid, he would not be able to serve as your Primary Care Physician. On your commercial health insurance card, it would list PPO or HMO. For an HMO you are required to have an in-network doctor and Dr Urick is not in network for any plan.***

NO, I do not have health insuranceYES, I have MEDICARE (If you have Medicare, We cannot take you as a patient)YES, I have MEDICAID (If you have Medicaid, We cannot take you as a patient)YES, I have insurance and it is a PPO.YES, I have insurance and it is an HMO (If you have an HMO, we cannot take you as a patient)

AN EXPLANATION OF URICK INTERNAL MEDICINE - A DIRECT PRIMARY CARE PRACTICE

Urick Internal Medicine is a Direct Primary Care Practice. DPC, as we call it, works well for everyone. Individuals who are uninsured find this to be a great fit. DPC also works well for those with high-deductible health plans and/or HSA accounts. I still recommend that individuals have catastrophic health insurance coverage or consider enrollment in health sharing plans/health sharing ministries. DPC is NOT a substitute for health insurance.

• DPC is not "alternative medicine". Dr Urick is a physician who practices evidence based medicine.

• Although I do not accept insurance, due to government regulations, I am unable to see patients who are enrolled in Medicare or Medicaid (due to Government Regulations). If an individual joins my practice and becomes Medicaid eligible they would need to find a new physician.

• LAB AND MEDICATION PRICES
I offer deeply discounted lab prices through my contract with QUEST. Somes patients may opt to use their insurance card instead. I can dispense generic medication in my office (usually 80-90% discounted compared to a pharmacy. Even those with medical insurance can save with these prescription discounts.

• NATUROPATHIC "MEDICINE"
If patients choose to see naturopathic people (NDs), they will not be a good fit for my practice, I respect one's desire to seek out the care that they feel is best. I only collaborate with physicians who have an MD/DO. If patients have a board certified Integrative Medicine Physician (MD/DO) I find no issue with that.

If a patient sees a naturopathic person or other healthcare practitioner that is not licensed to order labs, I will not order on their behalf. There is a reason those practitioners are unable to order lab tests: they lack medical school training. Training in healthcare does matter.

• MY MEDICAL PHILOSOPHY

Some believe that by becoming a member of my practice that they are able to dictate care. I am still an Internal Medicine physician who will, after evaluation of my patients, determine the best lab tests to order, medications to prescribe, and what needs should be addressed by a specialist physician. Becoming my DPC patient does not give carte blanche to "google" symptoms and demand that certain blood work be performed.

I also do not believe in "hormone specialists". The only hormone specialists are physicians (MD/DO) who are board certified in Endocrinology. There are non-physician practitioners falsely claiming to be an expert and inappropriately treating individuals.

I do not ascribe to leaky gut, "adrenal fatigue" or any non medically recognized condition diagnosed by a non-physician.

1. I have read the above philosophy of Dr Urick's practice method and I agree to proceed with my inquiry.*

Yes, I agreeNo, I do not agree and will not submit this form

2. I understand that Dr Urick/Urick Internal Medicine does not prescribe pain medications/opioids. Pain management will need to be handled by a pain management physician.*

Yes, I understandNo, I do not agree and will not submit this form

3. I understand that Dr Urick/Urick Internal Medicine does not prescribe stimulant medications for ADD/ADHD. These medications would need to be handled by a Psychiatrist.*

Yes, I understandNo, I do not agree and will not submit this form

4. I understand that Dr Urick/Urick Internal Medicine does not prescribe Benzodiazepines (e.g. Xanax, Ativan, etc) These medications would need to be handled by a Psychiatrist.*

Yes, I understandNo, I do not agree and will not submit this form

5. I understand that Dr Urick/Urick Internal Medicine will not complete disability forms for patients who have been under his/our care for the first 12 months. We will comply with faxing records to a disability physician, etc*

Yes, I understandNo, I do not agree and will not submit this form

6. I understand that Dr Urick/Urick Internal Medicine does not prescribe testosterone replacement therapy and any male patient would need evaluation by a Urologist/Endocrinologist.*

Yes, I understandI am a female, this is not applicableNo, I do not agree and will not submit this form

Do you have any particular questions? If so please feel free to share below.

CLOSING INFORMATION

Thank you for completing this inquiry. We will reach out to you within 2-3 business days and set up a time to discuss any other questions you may have and to see if you would be a good fit