Walk In Urgent Care Face Sheet
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1A+ Walk-In Urgent Care
Face Sheet
PLEASE PRINT
Date:
Patient Name:(Iast, First, MI)
Sex M
F
Address:(No., Street)
Apt.
City:
State:
Zip:
Home Phone:( )
Work Phone:( )
Cell Phone:( )
Date of Birth:
SSN#:
Marital Status:
How did you hear about us?
Responsible Party:
Relationship:
SSN#
Date of Birth:
Driver's License#:
Street Address:
Apt.
City:
State:
Zip:
Home Phone:( )
Cell Phone:( )
Emergency Contact:
Phone:
Insurance Subscriber Information:
Name of Policy Holder:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone#:( )
SSN#:
Relationship to Patient:
Name of Insurance Company:
Member ID #:
Group #
Please remember that Insurance is considered a method of reimbursing the patient fees paid to the Physician, but
usually not designed to pay the entire fee. Because insurance companies vary in the amount they will pay for services, It is
Ultimately your responsibility to pay the portion of the bill not paid by your insurance company ( unless otherwise
restricted by law or agreement we might have made with the insurer).
I authorize the release of any medical or other information necessary to process claims from A+ Walk-In Urgent
Care Medical Clinic. I also request payment of government benifits either to myself or to the party who accepts
assignment. I authorize payment of medical benifits to A+ Walk-In Urgent Care Medical Clinic for services rendered.
Patient Signature/ Authorized Person's Signature
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Parent category: Medical