Please bring your insurance card and ID to your visit
Please be aware that this does not reserve your spot in line, but allows you to complete forms ahead of time to reduce your wait.
* Required Fields
If you are enrolled with Medicare, Medicaid (Peachstate, Ambetter, Wellcare), or TriCare, please call us for further information at 770-502-2121
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.
Authorization for Release of Medical Records : I authorize the release of any or all medical records or information, including psychiatric, drug, alcohol, HIV, and substance abuse records, to the referring physicians or agencies involved in the payment of the patient's account, or other involved in the performance of quality assurance.
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.
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.
Receipt of Privacy Notice : I acknowledge that I have been made aware of, read, and understand the PROVIDER NOTICE OF INFORMATION PRACTICES which outline my rights with regards to my medical records an that a digital or physical copy will be provided upon request.
A photocopy of this authorization shall be considered as effective as the orginal.
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.
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 financial policy stated above.