Rainbow Kids Urgent Care Registration Form

PATIENT REGISTRATION
CONTACT INFORMATION
Reason For Visit*
PCP*
Please List Any Impairments (visual/hearing/Other)
Patient Name*

PrefixFirst NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Age
Patient Sex
Primary Language
Patient Race/Ethnicity
Hispanic

YESNO
Email*
example@example.com
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Pharmacy/City/Street*
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
REFERRAL INFORMATION
How did you find out about our office?*
Our goal is to provide you with extraordinary care & service. Is there anything we can do to give you the best experience?
RESPONSIBLE PARTY

(If other than the patient.)
Name*

First NameLast Name
Relationship to Patient*
Address (Leave Blank if same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email (Leave Blank if same as above)
example@example.com
INSURANCE INFORMATION

Insurance Information
PLEASE NOTE:

We ACCEPT Kaiser

While we strive to accept ALL insurances we currently DO NOT ACCEPT the following:

- HealthNet Medi-Cal (We accept a few HealthNet insurances - please CALL to verify)

- Kaiser Medi-Cal (We accept Kaiser without Medi-Cal)

- Connected Care

- Western Health Advantage with Mercy Medical Group

- Partnership Healthplan

- The following medical groups: Imperial, WellSpace, UC Davis

If you are unsure, please do not hesitate to call before completing this form
ARC (Always Rainbow Care) Member:*

YESNO
Self Pay

YES (Ask about our low cost membership service)NO
Primary Insurance Carrier
Insured Name
Insured DOB
Patient's Relationship to Insurance Prescriber
Insured's Employer
Insured's SS#
Insurance ID #
Enter your insurance ID # from your card
Insurance Group #
Is Insured's Address the Same as Patient's Address*

YESNO - Please fill below
Insured's Phone Number

Area CodePhone Number
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload your insurance card

Front and Back
Browse Files

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Browse Files

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Secondary Insurance Carrier

If double coverage is applicable.
Insurance Company Name
Insured Name
Insured DOB
Insured's Employer
Insurance Group #
Insured's Phone Number

Area CodePhone Number
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Financial Policy
OUR FINANCIAL POLICY
We are committed to providing you with the best possible care and would be happy to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your financial responsibility. If you do not have insurance, we expect payment in full for all treatment at the time of service, unless other arrangements have been previously made. We have created an online payment service through our website at rainbowkidsurgentcare.com

If you have insurance, it is your responsibility to verify that your policy is in effect at the time your services are performed. Otherwise, you are responsible for payment at the time of service.

Insurance is an agreement between you and your insurance company. We will inform you if we are participating with your insurance plan and will handle your claim according to our agreement with the insurance company. We file insurance claims as a courtesy to you, our patient. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, maximum limitations, covered charges, secondary insurances, “usual and customary” charges, etc., other than to supply necessary factual information. If payment is not received from your insurance company by us within a reasonable period of time, the balance of the account becomes your responsibility. I hereby authorize and agree as follows:
- I authorize the use of this information on all my insurance submissions.
- I authorize release of information to all my insurance companies.
- I understand I am responsible for my account.
- I authorize payment directly to my doctor.
- I understand benefit information given to me by Rainbow Kids Urgent Care is not a guarantee of payment.
- I understand that full payment of my account must be received at the time of my appointment electronically if I do not have insurance and any remaining balance after insurance must be paid within 90 days or I may be sent to a collection agency.
- A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any
  information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by
  law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit
  reporting agency, the debt shall be void and unenforceable.
I have read the above Financial Policy and understand that I am financially responsible for all charges, whether or not they are paid by my insurance.
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature of patient/parent/guardian*

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Relationship to patient (if signed by personal representative of patient):

Privacy Policy
NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Rights

You have the right to:

Get a copy of your medical record
Request corrections to your medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we have shared your information
Receive a copy of this Notice of Privacy Practices
File a complaint if you believe your privacy rights have been violated

Our Uses and Disclosures

We may use and share your information as we:

Treat you and coordinate your care
Bill for services rendered
Conduct healthcare operations and improve our services
Comply with the law and respond to legal requests
Report public health and safety issues
Work with medical examiners and funeral directors
Address workers’ compensation, law enforcement, and government requests

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will promptly inform you if a breach occurs that may have compromised the privacy or security of your information.
We will not use or share your information other than as described here unless you give us written permission.

Uses and Disclosures Requiring Authorization

We will obtain your written authorization before using or disclosing your medical information for purposes not covered by this notice, including:

Marketing purposes
Sale of your health information
Most sharing of psychotherapy notes

Your Choices

You can choose how we share information in situations such as:

Sharing with family, friends, or others involved in your care
Disaster relief efforts
Inclusion in a hospital directory

How to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
I had the opportunity to review and/or obtain a copy of this office’s Notice of Privacy Practices.
Patient Name*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Date*

MonthDayYear
Date
Signature of patient/parent/guardian:*

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Relationship to patient (if signed by personal representative of patient):
Please check the box if we are able to leave a message with medical & financial information on phone numbers.

Yes
Please list individuals names that we are allowed to release financial and medical information to:
* You May Refuse to Sign This Acknowledgment*
Consent For Treatment
PATIENT CONSENT FOR TREATMENT AND FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I authorize medical treatment as deemed necessary and appropriate by the physicians of Rainbow Kids Pediatric Urgent Care and their employees participating in my child’s care.

With my consent, Rainbow Kids Pediatric Urgent Care may use and disclose Protected Health Information (PHI) about my child to carry out treatment, payment, and healthcare operations. Please refer to the Rainbow Kids Pediatric Urgent Care Notice of Privacy Practices for a more complete description of such uses and disclosures.

With my consent, Rainbow Kids Pediatric Urgent Care may:

Call my home or other designated location and leave a message on voicemail or in person regarding items that assist the practice in carrying out treatment, payment, or healthcare operations. This may include appointment reminders, insurance items, and calls pertaining to my child’s clinical care, including laboratory results.

Mail or email communications as necessary for treatment, payment, or healthcare operations, including statements, appointment reminders, and other necessary correspondence.

I have the right to request that Rainbow Kids Pediatric Urgent Care restrict how it uses or discloses my child’s PHI to carry out treatment, payment, or healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Rainbow Kids Pediatric Urgent Care's use and disclosure of my child’s PHI to carry out treatment, payment, and healthcare operations.

I understand that I may revoke my consent in writing, except to the extent that the practice has already made disclosures relying on this consent.
Patient Name

First NameLast Name
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Signature of patient:

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X-Ray Consent Form
Rainbow Kids Pediatric Urgent Care
X-Ray Consent Form

If your child requires an X-ray, this consent form will remain valid for all future visits to Rainbow Kids Urgent Care unless revoked in writing.

Release of Liability
I understand that while Rainbow Kids Urgent Care follows all safety protocols, there are inherent risks associated with medical imaging. I acknowledge these risks and release Rainbow Kids Urgent Care, its physicians, technicians, and staff from any liability related to the performance of the X-ray procedure.

Pregnancy Disclosure (For Female Patients of Childbearing Age)
If my child is of childbearing age or capable of pregnancy, I confirm that I WILL disclose any known or suspected pregnancy to the medical staff.

I understand that exposure to X-ray radiation may be harmful to an unborn fetus, and additional precautions may be necessary.

Consent Validity
This consent form applies to all future X-rays performed at Rainbow Kids Urgent Care unless revoked in writing. I understand that it is my responsibility to notify the healthcare providers of any changes to my child’s health status that may impact X-ray procedures.

Acknowledgment and Agreement
I have read and understood this X-ray Consent Form, and I agree to the terms outlined above.
Signature

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Patient Rights and Responsibilities
Patient Rights and Responsibilities

Patient Rights
At Rainbow Kids Urgent Care, we respect your rights as a patient and are committed to providing quality healthcare in a respectful and compassionate manner.

As a patient, you have the right to:

Access to Care – Receive medical care regardless of race, gender, age, national origin, disability, or financial status.
Respect and Dignity – Be treated with dignity, respect, and consideration in a safe and supportive environment.
Privacy and Confidentiality – Have your medical records and personal health information kept confidential in accordance with HIPAA regulations.
Informed Consent – Be fully informed about your diagnosis, treatment options, risks, and alternatives before consenting to any treatment.
Refusal of Treatment – Decline treatment, to the extent permitted by law, and be informed of the medical consequences of such decisions.
Access to Medical Records – Request and obtain a copy of your medical records, subject to applicable legal restrictions and policies.
Participation in Care – Be involved in decisions regarding your healthcare and treatment plans.
Emergency Care – Receive emergency care when needed without unnecessary delays.
Second Opinion – Request a second opinion regarding your treatment and diagnosis.
Complaints and Grievances – Express concerns about the care received and file a complaint without fear of retaliation.

Patient Responsibilities
To ensure a positive healthcare experience for all, patients and their families also have responsibilities, including:

Providing Accurate Information – Give complete and accurate health information, including medical history, medications, and allergies.
Following Treatment Plans – Adhere to the prescribed treatment and follow the recommendations of healthcare providers.
Respecting Healthcare Staff – Treat all healthcare providers, staff, and other patients with courtesy and respect.
Keeping Appointments – Arrive on time for scheduled appointments and notify the clinic if you need to reschedule.
Understanding Your Care – Ask questions if you do not understand your diagnosis, treatment, or instructions.
Financial Responsibility – Provide accurate insurance information and fulfill financial obligations related to your care.
Observing Clinic Policies – Follow all clinic policies, including infection control and safety procedures.

Authorization for Treatment
I hereby authorize the healthcare providers at Rainbow Kids Urgent Care to provide medical evaluation and treatment to the above-named patient. I understand that treatment may include, but is not limited to, diagnostic tests, laboratory tests, imaging studies, medical procedures, and medication administration as deemed necessary by the provider.

Consent for Minors
If the patient is under 18 years of age, I affirm that I am the parent or legal guardian authorized to consent to medical treatment on their behalf. I understand that in case of an emergency, the healthcare providers will act in the best interest of my child if I am unable to be reached.

I have read, understood and agree to follow the above policies. I have had the opportunity to ask Rainbow Kids Urgent Care staff for help with understanding each policy. I give consent for Rainbow Kids Urgent Care staff to evaluate, treat and render services to my child or the child listed under my care.
Patient Name

First NameLast Name
Parent/Legal Guardian Name

First NameLast Name
Relationship to Patient:
Please upload your driver license
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Signature

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I have understood all of the new patient paperwork and have filled it out to the best of my ability. Patient/parent/guardian signature.*

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PATIENT REGISTRATION

CONTACT INFORMATION

REFERRAL INFORMATION

RESPONSIBLE PARTY

INSURANCE INFORMATION

Please upload your insurance card

Secondary Insurance Carrier

OUR FINANCIAL POLICY

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT

Consent For Treatment

X-Ray Consent Form

Patient Rights and Responsibilities

Please upload your driver license