Online Check-In Form

THE ONLINE CHECK-IN IS NOT AN APPOINTMENT!

COVID-19 TESTING:

*****NO MEDI-CAL OR KAISER ACCEPTED FOR COVID TESTING********

VERIFY IF YOUR INSURANCE IS ACCEPTED BY GIVING US A CALL!

IF YOU ARE HAVING SYMPTOMS, PLEASE FILL OUT THIS FORM AND CALL US WHEN YOU ARE IN THE PARKING LOT.

VERIFY TESTING CENTER INFORMATION AT 559-324-7001 IF YOU HAVE QUESTIONS OR CONCERNS.

TELEMEDICINE:

******NO HMOs, MEDI-CAL, OR KAISER FOR TELEMEDICINE. ONLY PPOs ACCEPTED.

1. Complete the form

2. YOU MUST CALL TO CONFIRM SUBMISSION.

3. Same-day phone call with a healthcare provider. Wait time is dependent on in-person patient volume.
Name*

First NameLast Name
Date of Birth*
Format: (MM/DD/YYYY)
Sex:*

MaleFemale
Select a Reason *
Are you a new patient?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number: *
Format: XXX-XXX-XXXX
Email*
Format: myname@example.com
Preferred Pharmacy*
How would you like to pay?*
Driver's License/Identification Card:*

Front Side Only
Cancelof
Insurance Card: Front Side

Cancelof
Insurance Card: Back Side

Cancelof
Terms & Conditions*

I confirm the information provided is true and accurate. Any incorrect information will result in delays.

Assignment of Benefits*
In the event the patient, his/her authorized representative or the guarantor signing below, is entitled to benefits of any type arising out of any policy of insurance the patient or any other party liable for the patient those benefits are hereby assigned to Clovis Urgent Care Medical Center for application to the patient’s bill. Such payment shall discharge the insurance company of any obligations under the policy to the extend that the payment has been made according to the terms of the policy. The undersigned shall remain responsible for all charges not paid by the insurance company and/or covered by this assignment. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable for this patient is hereby assigned to Clovis Urgent Care Medical Center.
Signature*

Clear
Patient Consent*
I hereby grant permission for the providers and staff (as directed by the providers) of Clovis Urgent Care Medical Center to perform any medical or surgical treatments as may be deemed necessary in the diagnosis and treatment of said patient.
By signing this form, you are granting consent to Clovis Urgent Care Medical Center to use and disclose your Protected Health Information (PHI) or the purpose of treatment, payment, and healthcare operations. Our Notice of Privacy Practices provides more detailed information about how we may use the disclose this protected information. Before you sign the consent, we encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our office at 559-324-7001.

You have the right to request us to restrict how we use and disclose your PHI for treatment, payment, or healthcare operations. We are not required by law to grant you request; we are bound by our agreement. If you refuse to sign and/or revoke this consent, Clovis Urgent Care Medical Center may refuse to treat you as permitted by section 164.506 of the code of Federal Regulations. You have the right to revoke this consent in writing, except to the extent we already have used, or disclosed you PHI in reliance on your consent. 


Signature*

Clear
Financial Policy*
Thank you for choosing Clovis Urgent Care Medical Center for your health care needs. We are committed to your treatment being successful. Please understand that payment of you bill is considered a part of your treatment. Please take a moment to carefully read and sign our financial responsibility policy.

All payments will need to complete our registration forms prior to seeing the provider.

We accept Cash, Check, Visa, Mastercard, Discover, and American Express.

All co-payments, deductible, and co-insurance amounts must be paid at the time services are rendered. 

Any patient who does not cancel their appointment with a full 24-hour notice will be subject to a $25 miss appointment charge.

PPO Contacts

For contracted PPO’S, the patient is responsible for verifying that the provider is on a plan. As a courtesy, we will bill all PPO insurance for our patients; however, your medical account is your responsibility to pay. If we have not heard from your insurance company within 45 days of our billing date, we will expect payment from you.

Returned Checks

All returned checks will be subject to a $30 handling fee.

Collections 

Any amounts due that are not paid in full within 90 days will be forwarded to a collection agency. In the event of legal action should become necessary to collect any unpaid balance due for medical service rendered to you or your family, you agree to pay reasonable attorney fees, or other such cost deemed appropriate by the court. 
I have read and agree with the terms and conditions in the Financial Policy,

Signature*

Clear
Should be Empty: