WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Home Phone: Cell Phone: Work Phone:

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1 WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel Phone: Emergency Contact: Relationship: Tel Phone: EMPLOYER Employer Name: Employer Address: Employer Telephone: Contact Person: Occupation: WORKER COMPENSATION CARRIER Worker Compensation Carrier: Carrier Address: Carrier Phone Number: Adjuster s Name: Injury Verified By (For Office Use): Coverage Verified by: Claim Number: INJURY INFORMATION Date of Injury: Time AM PM Place of Injury: Accident reported to employer? Yes No Name of person you reported accident to: Give full description of how accident happened

2 Have you lost time from work? Yes No How much? Other doctors seen for this condition: Yes No Doctor s Name: Were X-Rays taken? Yes No Other Tests? Yes No If yes, by whom? Please list test(s) and result(s): Any previous Worker Compensation injuries? Yes No Describe previous Worker Compensation injuries: Date(s) of previous injuries: AUTHORIZATION I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment in the event that my claim for Workers Compensation benefits is denied. Patient s Signature Date

3 Receipt of Notice of Privacy Practice Written Acknowledgement Form I,, have received a copy of Physicians Now LLC., Privacy Notice. Date Patient refused to Sign Employee Signature

4 Request for Protected Health Information Who may we release your personal and medical information to other than yourself and/or medical physicians? Please include the relationship to the patient. Please indicate where it is OK to leave you a detailed sensitive message. Please check all that apply: HOME WORK CELL I understand if I lose or misplace my prescription I will not receive another one without being re-evaluated.

5 Patient Financial Policies Thank you for choosing Physicians Now LLC, for your medical needs. We are committed to providing excellent medical care. As part of our professional relationship, it is important for you to understand our financial policies. Whenever possible we will file your claims with your insurance carrier on your behalf. In most cases reimbursement is be received within 45 to 60 days although there are some exceptions. We charge a billable urgent care fee. Some insurance company may not cover this fee. However, it is ultimately the patient s responsibility to know and understand what services are covered under their individual insurance policy. We cannot file claims to Workers Comp programs unless your employer has authorized your treatment. We can file automobile-related accident claim if you provide a verifiable auto-insurance claim number. Patients without insurance coverage or verifiable workman-comp or auto-insurance claim numbers are required to pay the balance in full at the time of service. Common reasons for insurance claim denials include, but are not limited to: Pre-existing medical condition(s) Patient responsible for meeting policy deductible Insurance not in effect at the time of service Coverage by more than one plan in which coordination of benefits has not been arranged Policy maximum has been reached No referral for the service (if the policy requires you to list a primary care physician) Medical services rendered is not covered by the insurance policy To assist in expediting your claim, you will be asked at every visit to verify your information and make any applicable changes. We will also need to obtain a copy of your D/L and insurance card with every visit. Please inform us of any demographic and insurance changes. If your insurance has changed or if you have two insurance carriers, please advise the front desk staff and provide them the insurance cards. If any changes in your insurance information coverage is not provided and/or received within the insurance carrier timely filing period, the patient will become responsible for any balance of the account. Deductibles, Co-ins and Co-pays are always due at the time of service. No exceptions. We accept the following type of payment: Debit and credit cards: Visa, Discover and Mastercard Cash Self pay: Our services start at a minimum discounted rate of $ and may be higher depending on the complexity of your illness or injury. If any tests or procedure are recommended by the provider, you will be informed before-hand in order to make an informed decision. Balance Due after insurance company payment: We will send a statement to your billing address notifying you of any balances due. Any unpaid balance is patient s responsibility and payment in full is due upon receipt of the statement. Payment not made within 30 days of the statement issue date is deemed past due. Past due accounts are subject to a $25.00 monthly late fee. Payments not receive within 60 days of statement date will be sent to the collection agency and/or attorney. You will be responsible for all collection cost incurred, including attorney s and court fee, if applicable. If you are unable to pay the balance due in full, you must contact our billing office to discuss possible payment options. If your account is assigned to a professional collection agency, you will no longer be able to receive services from the providers at Physicians Now Urgent Care Center, until your delinquency is cured. Thereafter, any future services rendered will require that you pay upfront and in full at the time of service. If your statement balance is paid by check and the check return unpaid by your bank for any reason, a $50.00 returned check fee will be added to your account. Above the past due policy above will also be activated. I have read, understand, and agree to the above financial policy. I also understand that this office will file an insurance claim on my behalf based on the information I provide. I also understand that I will be fully responsible for payment of any and all medical services denied by my insurance company as applicable by state and / or federal law. I authorize my insurance benefits be paid directly to Physicians Now Urgent Care Center. I authorize Physicians Now Urgent Care Center to release pertinent medical information to my insurance company when requested or to facilitate payment of claim. Print Patient Name Patient DOB Signature of Patient, Parent or Guardian Date

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