ENGLISH Patient Registration, CC, and History

After Hour Pediatrics Urgent Care Clinic

PATIENT REGISTRATION
Patient Name:

First Name Last Name M.I
Date of Birth

Month Day Year
Date
Gender
Family Member 1 Name: (leave blank if no additional family to register)

First Name Last Name M.I
Family Member 1 Date of Birth

Month Day Year
Date
Family Member 1 Gender
Family Member 2 Name: (leave blank if no siblings)

First Name Last Name M.I
Sibling 2 Date of Birth (leave blank if no siblings)

Month Day Year
Date
Sibling 2 Gender (leave blank if no siblings)
Sibling 3 Name: (leave blank if no siblings)

First Name Last Name M.I
Sibling 3 Date of Birth (leave blank if no siblings)

Month Day Year
Date
Sibling 3 Gender (leave blank if no siblings)
Sibling 4 Name: (leave blank if no siblings)

First Name Last Name M.I
Sibling 4 Date of Birth (leave blank if no siblings)

Month Day Year
Date
Sibling 4 Gender (leave blank if no siblings)
Contact for COVID Results: Cell Phone
Email
example@example.com
Primary Insurance Subscriber
DATE OF BIRTH

Month Day Year
Date
Sex: (enter M or F)
Name

First Name Last Name
Email
example@example.com
Address

Address

Street Address Line 2

City State

Zip Code
Cell Phone Number
Home Phone Number
Work / Other Phone Number
Parent #2
DATE OF BIRTH

Month Day Year
Date
Name

Last Name First Name
Email:
example@example.com
Check "Yes" if Parent #2 has the same address as Primary Insurance Subscriber

YES
Address

Address

Street Address Line 2

City State

Zip Code
Cell Phone Number
Parent #2
Home Phone Number
Parent #2
Work / Other Phone Number
Parent #2
Patient’s Primary Physician
How did you learn about After Hour Pediatrics?

Pediatrician Friend Yelp Google Other
AHP bills to primary insurance only with whom we are contracted. It is patient’s responsibility to know their health plan and costs associated with using AHP. Please review and sign the Credit Card Authorization.

Due to our contracts, AHP does not bill for durable goods such as crutches, ace bandages, nebulizers, etc. We sell these items at cost as a convenience for our patients. We will provide you with a receipt so that you may seek reimbursement. Payments including copays, deductibles, coinsurance or any additional fees charged by your insurance are due at the time of service regardless of which parent provides insurance coverage. This is also the person who will receive the bill and is responsible for any outstanding payments.
-CONSENT-
1. I certify that the above information is true and I consent to any medical or surgical treatment rendered the patient under the general or special instructions of the physician.
2. I may review in detail After Hour Pediatrics’ Privacy Practices and may request special privacy considerations.
3. I understand the above insurance billing and payment information, and hereby accept responsibility for all charges related to this treatment, including any charges which are not covered by insurance.
4. I hereby authorize AHP to send messages to me via my email, which may be non-secure, and/or to leave telephone/text messages about Billing and Insurance matters, Medical Information, such as lab results and follow-ups.
Name of Credit Card Holder
Signature of Credit Card holder

Clear
Date

Month Day Year
Date

After Hour Pediatrics Urgent Care Clinic

Credit Card Authorization/Credit Card on File Policy
WITH confirmed eligibility at check-in: After Hour Pediatrics Urgent Care Clinic (AHP) will electronically scan the authorized credit/debit or HSA/FSA card into AHP’s secure credit card system. You may call at any time to update or change this card. All cards are encrypted and we can only view the last 4 digits of your card and the expiration date.

The insurance company will send an Explanation of Benefits (EOB) to AHP and to the insured. AHP may receive the EOB before the patient. This EOB will explain whether a balance is due to AHP or if a refund is due to the patient. All EOB’s can be accessed on line by the insured or by calling the insurance company. The number is on your insurance card. We process credit cards upon receipt of the EOB.

This signed authorization covers charges made by AHP to your credit card due to:

(1) A deductible that has not been satisfied and is your responsibility

(2) A co-pay or co-insurance that your insurance assigns as your responsibility and/or

If a refund is due, it will be processed back to your card as we enter your EOB. It is our policy not to hold any overpayments on accounts. Many times you will see a charge made to your card and this is due to the fact that your copay for urgent care visits is higher than the regular office visit copay. You may confirm the amount with your insurance company. The amount charged/refunded should match exactly the amount of the “patient responsibility” portion on the EOB provided by your insurance company.

WITHOUT confirmed eligibility at check-in: If insurance eligibility cannot be confirmed at check-in,

AHP requires a credit card on file and a deposit of $199.00, which will be held for 10 business days while we work with you to obtain benefits and eligibility so that we can bill on your behalf. If you are eligible for insurance benefits, we will bill the insurance company and you will be refunded the $199 less your assigned responsibility.

If the insurance company determines non-eligibility, the credit card will be charged full service rates.

If you have questions about your charges we are always willing to discuss with you. You may contact AHP billing at 650-579-6581 option 3 or ahpsanmateo@gmail.com. If you reverse a credit card charge, AHP charges a cancellation fee of $25 per charge in addition to your regular fee.

I authorize AHP to keep my credit/debit card information and signature on file in order to charge my credit/debit card for balances due. This Credit Card Authorization/Credit Card On File Policy will remain in effect until notified by responsible party in writing.

I understand statements are not sent by AHP, my EOB serves as a statement of my responsibility and I agree to keep my account current and in good standing.
Name of Credit Card holder
Signature of Credit Card holder

Clear
Date

Month Day Year
Date
*BENEVOLENCE FUND*

AHP wants to care for children. If you struggle to pay the fee, please write a letter to AHP so we may assist you.

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After Hour Pediatrics Urgent Care Clinic

Primary Insurance Subscriber

Parent #2

After Hour Pediatrics Urgent Care Clinic

After Hour Pediatrics Urgent Care Clinic