Patient Registration Form ⋆ Lifeline Urgent Care

Your Gender

MaleFemale

Your City

Your Country

Enter Name of your Primary Care Physician

You Pharmacy Location

Your Pharmacy Zipcode

Your Employment Status

EmployedSelf EmployedNot Employed/RetiredStudent

Your Employer Name

Your Employer Mailing Address

Your Employer City:

Your Employer Zip Code

Your Employer Phone:

Primary Card Holder First Name

Primary Card Holder Last Name

Card Holder Date of Birth

Your Insurance ID Number

What do you need to be seen for today?

Acknowledgement of Receipt of Privacy Notice

I have been presented with a copy of Lifeline Urgent Care's Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state laws. I understand the contents of the notice, and I request the following restriction(s) concerning the use of my personal medical information:

Privacy restrctions that you are requesting:

Acceptance of Privacy Policy

Yes, I acceptNo, I do not accept

Financial Policy

We offer a significant discount for patients who pay their entire balance in full at the time of the visit. We also offer payment plans for self-pay patients who cannot afford to pay the balance in its entirety at the time of service. For patients with medical insurance, we cannot guarantee that your insurance carrier will pay for your visit, or that your visit will apply to your in-network benefits. We will, however, make every effort to ensure that your claim is paid at the best rate for you. After verification of benefits, if your annual deductible has been met, we will be glad to accept the co-insurance portion for services rendered. For your convenience, our staff will be glad to file your primary and secondary insurance claims; however, final responsibility is ultimately the patient's.

Assignment of Insurance Benefits

I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply. I also authorize Lifeline Urgent Care LLC to retrieve my medication history from any provider.

Acceptance of Assignment of Insurance Benefits

Yes, I acceptNo, I do not accept

For Patients with Insurance

I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance left. I also authorize Lifeline Urgent Care or my insurance company to release any information required to process my claims.

Your Signature Here:

Acceptance of Financial Policy

Yes, I acceptNo, I do not accept

For Patients without Insurance

I pledge to pay an up front amount of at least $150 for each visit. I understand that I am getting a discount today for my charges and that if I pay the amount in full on the date of service that my discount is higher. I understand that getting monthly bills is a privilege and I pledge to pay my bill in full within three months of my office visit.

Your Signature Here:

Acceptance of Financial Responsibility

Yes, I acceptNo, I do not accept

Date Signed:

Submit