Medical Visit -

Family Urgent Care
1831 Pittston Ave.
Scranton, PA 18505
Phone: 570-507-9517
Fax: 570-507-9520
(To be completed by patient)
Name: ___________________________________________ DOB: _______________________
Address: ______________________________________________________________________
City: _______________________________ State: _______ Zip Code: ____________________
Phone: (W) ___________________ (H) ___________________(C) _______________________
Social Security Number: _______________________________ Gender: ( ) M ( ) F
Emergency Contact
Name: ________________________________________________________________________
Relationship to patient: ___________________________ Phone: _________________________
Primary Care Physician: ___________________________ Phone: ________________________
Insurance Information
Insurance Company: ____________________________________________________________
Subscriber Name: _________________________________ Relationship: __________________
Social Security #: ____________________________________ DOB: _____________________
ID #: ____________________________________ Group #: _____________________________
Current or past medical conditions (check all that apply):
If there’s a family history of any of the illnesses listed below, please put an “F” next to that
) Asthma/Respiratory
) Cardiovascular (heart attack, high cholesterol, angina)
) Hypertension
) Epilepsy or Seizure Disorder
) GI Disease
) Head Trauma
) Diabetes
) Liver Problems
) Pancreatic Problems
) Thyroid Disease
) STDs
) Abnormal Pap smear
( ) Nutritional Deficiency
Other (Please Describe) ________________________________________________________
Are you taking any medications? Yes / No (Please circle)
How Often
Have you ever had surgery or been hospitalized for 24 hours or more? (Please describe)
What Happens?
Please remember in order for us to bill your insurance company, we need complete information.
Please cooperate with our reception staff in providing all the correct information. Although our
staff understands multiple insurance company guidelines, they do not have all the answers.
Please contact your insurance provider for a copy of your benefits guidebook, should you need
detailed information about your coverage.
When is my payment due?
Payment will be requested at the time of your visit. If we participate with your insurance all
copayments will be collected. We except cash only at this time. Please have all your insurance
cards ready when you wish to be seen. If we do not participate with your insurance we will have
you pay at the time of service and you may if you wish see if you can be reimbursed by your
insurance provider.
Fees we charge
You may notice information on your explanation of benefits form that relates to usual and
customary fees. FAMILY URGENT CARE fees are comparable to other physician
groups/clinic in the area and industry standard methods. We feel confident that our charges are
appropriate. If you have any questions about our policies please ask us.
Please note the following guidelines: Uninsured/Non-Participating- If you do not have insurance
coverage or if we are non-participating with your insurance payment in full is requested at the
time of service.
Commercial/Indemnity- If you have commercial insurance, you will be asked to pay at the time
of service rendered. We will then file your insurance claim for you, and the insurance company
will make the reimbursement change directly to you. Please note that your commercial policy is
a contract between you and your insurance company. We are not part of your plan therefore you
are responsible.
Managed Care Plan (HMO, PPO, POS, and EPO) - If we participate with your plan, we will
accept the appropriate pay as payments in full at the time services are rendered. We will file your
insurance claim for you. In case of some PPO and POS plans, we may later send you a statement
for the amount, which is your responsibility, according to the term of your policy. Please be
aware that some services may not be a covered benefit under your managed care plan. In that
case all non-covered services are your responsibility.
I have read the FAMILY URGENT CARE payment at the of services policy. I understand and
agree to this policy.
Signature: _____________________________________________ Date: __________________
Name: ____________________________________________________ DOB: ______________________
FAMILY URGENT CARE considers patient confidentiality to be of the utmost importance and concern. In
an effort to ensure that your privacy is protected, please read and sign the following consent form.
( ) I authorize FAMILY URGENT CARE to leave a message on my home and/or cell phone.
( ) I authorize FAMILY URGENT CARE to leave a message containing protected health information (i.e.
Lab and X-ray results) on my home and/ or cell phone.
( ) My protected health information may be left with another person, indicated below:
Name: _______________________________________________________________________________
Phone: ____________________________________________ Relationship: _______________________
( ) I DO NOT authorize FAMILY URGENT CARE to leave a message on my home and/ or cell phone.
Signature: ______________________________________________________ Date: _________________
Notice of Privacy
I fully understand the Notice of Privacy Practices and that medical information may be required to
process the insurance claim(s). I hereby authorize FAMILY URGENT CARE to apply for benefits on my
behalf for services rendered. I request that my insurance make payments directly to FAMILY URGENT
CARE. I have read and signed the Payment at Time of Service Policy and I fully understand this policy. I
understand I am responsible for all co-payments and all services not covered by my insurance.
Signature: ____________________________________________________ Date: __________________
Medical Assistance Patients ONLY
This is to inform you that FAMILY URGENT CARE will submit your medical claim for you. If the claim is
denied because you are over your visit limit for the year, or any other reason, you will be billed for all
charges incurred. Furthermore, our doctors will not be able to see you until the next calendar year when
your visit numbers are re-instated unless you are willing to pay for each visit. By signing below you
understand and agree to this protocol.
Signature: ___________________________________________________ Date: ___________________