The following questions pertain to the Patient’s Parents:
Patient Medical History
PLEASE CHECK ALL THAT APPLY
SURGICAL HISTORY -
MEDICAL HISTORY -
Acknowledgement of Notice of Privacy Practices -
I have been given the opportunity to read and have had any questions addressed concerning Lifeguard Urgent Care’s Notice of Privacy Practices.
You expressly consent and agree that, in order to discuss or service your accounts(s) or to collect amounts you may owe Lifeguard Urgent Care, and its officers, agents, affiliates, employees, and any affiliated or associated service providers and any third-party debt collection agency associated therewith (collectively, We may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you. You expressly consent and agree that We may also contact you by sending text messages, emails, using any e-mail address you provide to us, or by pre-recorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and pre-recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile telephone numbers, regardless of whether you incur charges as a result.
I request that the payment of authorized Medicare/insurance benefits be made on my behalf for any services furnished to CMS/insurance carriers and its agents any information needed to determine these benefits or benefits related to services. I hereby authorize Lifeguard Urgent Care garnish information to CMS/insurance carriers concerning my medical condition, illness and treatment to determine the benefits for related services. I hereby authorize (assign) my insurance carrier/CMS to make payment directly to Lifeguard Urgent Care for medical/diagnostic or surgical benefits payable for the services rendered. I understand that any unpaid balance not covered by this policy will be paid by me. I understand and agree (regardless of my insurance status), that I am ultimately responsible for the balance of any professional services rendered. I understand that I am responsible for any charges incurred if my account is sent to a collection agency and for any returned checks. I understand that CMS and/or other insurance carriers do no cover all office services/procedures. I agree to take full responsibility for any unpaid balances and that such payment will be made to Lifeguard Urgent Care for services rendered. I certify that the information I have given here is true and correct to the best of my knowledge. I will also notify you (the office) of any changes in the above information.
I, the patient or authorized patient representative, consent to any medical examination, evaluation and treatment regarding any illness, injury, and/or health concern affecting me at any time I present to Lifeguard Urgent Care for medical treatment. These services may include, but are not limited to laboratory procedures, x-ray examinations, injections, and medical and/or surgical treatment procedures.