My Urgent Care is a privately-owned, non-hospital affiliated Urgent Care system in Northern Virginia. We've been leaders in urgent care services and walk in clinics for over twenty-five years.Whether you need immunizations, physicals, have aches, flu, minor injuries or need any urgent care services for the entire family, My Urgent Care offers walk in convenience and same day doctor visits. Just walk in to any of our medical clinics. We have two locations are open till late and serve Fairfax, Alexandria, Arlington, Prince William and Stafford Counties.
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Content
MY URGENT CARE
Patient Information Form- PLEASE PRINT CLEARLY & FILL COMPLETELY
Account #
SELF PAY
RECEPTIONIST NAME:
INSURANCE VISIT
PATIENT INFORMATION
LAST NAME
FIRST NAME
STREET #(NO PO BOX)
STREET NAME
HOME PHONE #
APT #.
DATE OF BIRTH
NO
FT
SCHOOL NAME
PT
STATE/ZIP
SOCIAL SECURITY #
MARITAL STATUS
M
F
EMPLOYED STATUS EMPLOYER NAME
NO
EMPLOYER ADDRESS
CITY
GENDER
M
STUDENT STATUS
MIDDLE INITIAL
FT
S
D
W
SP
WORK PHONE #
PT
CELL PHONE # /EMAIL
PRIMARY CARE MD/NAME & #
INSURANCE SUBSCRIBER'S INFORMATION; (SPOUSE/PARENT, IF NO INSURANCE BILLING)
RELATIONSHIP TO PATIENT
STREET #(NO PO BOX)
LAST NAME
FIRST NAME
MIDDLE INITAIL
WORK PHONE #
APT #.
CITY
STATE/ZIP
STREET NAME
HOME PHONE #
DATE OF BIRTH
EMPLOYER NAME
GENDER
EMPLOYER ADDRESS
SOCIAL SECURITY #
CITY
MARITAL STATUS
STATE/ZIP
PRIMARY INSURANCE INFORMATION: My Urgent Care will file claim once with your primary insurance carrier only, if we are an
in-network provider, or your policy covers out-of-network providers ,or your policy covers emergency care.
INSURANCE NAME
POLICY NAME
POLICY TYPE
Group
INSURANCE ID #
POLICY GROUP#
(800)
Individual
HMO PLAN
Yes
INSURANCE PHONE #
No
$
Do you need a referral from
your Primary Care MD?
Yes
COPAY/DEDUCTIBLE
No
%
DEDUCTIBLES MET ?
Yes
No
EMERGENCY CONTACT INFORMATION (who is not residing with you):
RELATIONSHIP
FULL NAME
1. I
ER CONTACT'S ADDRESS
PHONE #
hereby assign, authorize and request the payment from my insurance /Workers
Compensation carrier be paid directly to My Urgent Care.
2. I certify that the information reported is correct, current, valid and complete. I understand that I will be charged $10 for
returned/forward mail or claim refilling, because of incorrect or changed information.
3. I hereby authorize the release of any information for this or any other related claim to my insurance/Workers
Compensation carrier, including my past and/or present employer(s).
4. I also realize that insurance /Workers Compensation coverage does not guarantee payment for services performed and
all charges are my responsibility, with payment in full due within 90 days from the date of service. I will contact my
insurance carrier/employer in 2 months, if my claims are still unpaid. I also agree that if there is any balances due or
may claim is disputed or denied by my insurance/employer, I will pay in full immediately upon notification from them.
5. I understand that the prices are subject to change.
6. In the event that my account is placed in the hands of a collection agency and/or an attorney, I agree to pay all costs
related to the collection thereof, which could be up to 50% additional to the balance due.
7. I will pay for this visit with
CASH OR
CREDIT CARD.
8. I understand that I am responsible for paying the $10.00 additional fee for services received on Evenings, Weekends
and/or Holidays.
Patient's /Legal Guardian's Signature
Date
If Patient is a Minor, please print your name
Date
Parent/Guardian Printed Name
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to
privacy regarding my protected health information. I understand that this information can and will be used to:
1. Conduct, plan and direct my treatment and follow-up among the multiple health care providers
who
may be involved in that treatment directly and indirectly.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received and read and I understand your Notice of Privacy Practices containing a more complete description
of the uses and disclosures of my health information. I understand that this organization has the right to change
its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address
above to obtain a current copy of the Notice of Private Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry
out treatment, payment or health care operations. I also understand that you are not required to agree to my
requested restrictions, but if you do agree you are bound to abide by such restrictions.
Patient Name:
Relationship to Patient:
Signature:
Date:
OFFICE USE ONLY
I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy
Practices Acknowledgement, but was unable to do so as documented below:
WOODBRIDGE URGENT CARE
FEATHERSTONE SQUARE SHOP. CENTER
14527 JEFFERSON DAVIS HIGHWAY
WOODBRIDGE, VA 22191
PHONE 703-497-1234
HAYFIELD URGENT CARE
HAYFIELD SHOP. CENTER
7598 TELEGRAPH ROAD
ALEXANDRIA, VA 22315
PHONE 703-778-0400