- Telemedicine & Urgent Care Provider

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EUC Patient Form

Please complete all information below

Step 1 of 4 - Patient Information

PATIENT INFORMATION - REQUIRED
Name*
First Middle Last
Mailing Address*
Street Address City State ZIP Code
Birth Date*
Date Format: MM slash DD slash YYYY
Social Security Number
Gender*
- Male
- Female
- Prefer Not to Answer
Marital Status*
- Single
- Married
- Divorced
- Widowed
CellPhone*
Home Phone
Email*
Enter Email Confirm Email
Emergency Contact Name
First Last
Relation to patient
Emergency Contact Phone Number

EMPLOYER AND PRIMARY CARE - REQUIRED
Employer*
Employer's Address
Street Address City State ZIP Code
Employers Phone Number
Primary Care Physician Name
First Last
Primary Care's Location
City State / Province / Region ZIP / Postal Code Country
Pharmacy Name
Pharmacy Location
City State / Province / Region

PARENT / GUARDIAN - CONDITIONAL
Required to be filled-out if accompanying a minor. Click NEXT if you're the patient.
Primary Parent or Guardians
First Name Last Name Relationship Phone Number

This section is required to be filled out If accompanying a minor. Otherwise, please click 'NEXT' to proceed
Parent of Guardian Social Security Number
Parent Guardians Gender
- Male
- Female
- Prefer Not to Answer
Parent / Guardians Marital Status
- Single
- Married
- Divorced
- Widowed
Parent / Guardians Birth Date
Date Format: MM slash DD slash YYYY
Parent / Guardians Mailing Address
Street Address City State / Province / Region ZIP / Postal Code

AUTHORIZATION - REQUIRED
Attach a copy of your photo ID and insurance card*
Drop files here or

Accepted file types: jpg, gif, png, pdf, heic, jpeg.
If using a mobile phone, please take a photo of your ID and insurance card and attach.
Authorization to pay benefits to provider:*
By checking this box, I agree with terms and policies below
I hereby authorize payment directly to the Executive Urgent Care of Indian Wells for the Medical Benefits for services rendered.

WHAT IS TELEMEDICINE?

Telemedicine (also sometimes called telehealth) services are a way to deliver healthcare services
locally to a patient when the healthcare provider is located at a distant site. Telemedicine is
generally defined as the use of electronic information and communications technology to
exchange medical information from one site to another site to provide medical or surgical
treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion or
medical advice to, a patient.

When a healthcare provider believes a patient may benefit from the use of telemedicine services, telemedicine can maintain a continuity of care with the provider and facilitate patient self-
management and caregiver support of the patient. Telemedicine services often provides a broader
access to medical care, eliminates transportation concerns, and increases comfort and familiarity
for patients and their families when located in their own homes or other local environments.

However, telemedicine uses new communications technology for which there is little research
supporting its effectiveness. For example, telemedicine services may not be as complete as in-
person healthcare services because the healthcare provider will not always be able to observe
subtle non-verbal communications such as a patient's posture, facial expression, gestures, and
tone of voice.

Telemedicine may transfer medical information through the use of interactive, real-time
audio/visual technology (for example, video conferencing) or electronic data interchange (for
example, computer-to-computer exchanges), or it may transfer medical information through the
use of store-and-forward technology (for example, emails). While precautions are taken to secure
the confidentiality of telemedicine services, the electronic transmission of medical information
can be incomplete, lost or otherwise disrupted by technical failures. Additionally, despite such
measures, the transmission and storage of medical information can be accessed by unauthorized
persons, causing a breach of the patient's privacy.

I read and understand the information provided in this document. I discussed any question I had
with my doctor and all of my questions were answered to my satisfaction.

I hereby authorize Executive Urgent Care of Indian Wells to release any and all of my information necessary to process this claim.

NARCOTIC POLICY
====================
To our valued patients,

Due to the changing landscape of medical care and concerns over improper prescribing and overuse of narcotic pain medications, Executive Urgent Care will no longer issue prescriptions for chronic pain medications or other controlled substances that are being written by primary care or specialty providers.These medications must be managed by your specialist or primary care provider. If your primary care or specialty provider is unable to see you and is willing to approve EUCIW writing you a short-term prescription until that provider can schedule a face-to-face visit with you, have the provider call EUCIW and speak to our office staff or provider on duty.EUCIW will do all we can to assist in writing a short-term prescription. This will be on very limited basis, and will not be construed as routine practice.We urge patients to schedule appropriate and timely appointments with their primary care or specialty providers to facilitate ongoing management of chronic medication needs. We appreciate your understanding and look forward to caring for any of your other urgent care needs.The Physicians, Providers and Staff of Executive Urgent Care

FINANCIAL POLICY
====================
Here at Executive Urgent Care of Indian Wells, we are committed to providing our patients with quality medical care and to avoid any misunderstandings, we have created this financial policy to clearly outline the patient and practice financial responsibilities.

PATIENT RESPONSIBILITY
====================

It is the patient’s responsibility to know what is covered under the insurance plan and what is not covered under the insurance plan. In addition, it is the patient’s responsibility to verify which facility is contracted with the insurance plan. To find more information about the insurance plan you may call the number on the insurance card.It is the patient’s responsibility at the time of service to pay any and all co-payment, deductible, co-insurance, or any other charged specified by the insurance plan. Medical services that are not covered by the insurance plan are the responsibility of the patient.

PAYMENT POLICY
====================

Payments will be collected at time of service. We accept cash, debit cards and all major credit cards.The adult accompanying a minor is responsible for any payments due at the time of service.

INSURANCE BILLING
====================

In order to bill your insurance company we will require all necessary information at the time of service.Once we receive payment from the insurance company, if for any reason there is a remaining balance, that is the patient’s responsibility, a statement will be mailed to the attention of the patient to the address we have on file. Balance will be due upon receipt. Please plan accordingly to settle the balance or contact the billing department at (877) 374-9148.

OUT OF NETWORK & NON INSURED
===========================

Payment must be paid in full at the time of serviceLabs, X-Ray, or any other procedures will be at an additional charge.
A code summary will be provided to the patient to submit to any out of network insurance companies for reimbursement. If for any reason the insurance company does not pay for the full cost of the services rendered, the patient will be considered responsible. You expressly consent and agree that, in order to discuss or service your account(s) (the “Accounts”) or to collect amounts you may owe Executive 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 email 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.

Our practice firmly believes that a good patient-provider relationship is based upon understanding and good communication. If you have any questions or concerns please feel free to talk to our staff. We are here to help you. Your signature below confirms that you have read and understand this financial policy.

I authorize the use and/or disclosure of my protected health information as set forth below:The only protected health information that may be used or disclosed is any information provided by me to my provider, or any information gathered or ascertained by my provider as a result of any physical condition, medical history, radiological or other medical procedures.The name, or other specific identification, of the person(s) or class of person(s) authorized to make the use/disclosure of my protected health information: My provider, his medical or technical assistances, and all duly authorized office personnel or staff of the provider.The name, of other specific identification, of the person(s) or class of person(s) authorized to make the use.disclosure of my protected health information: Executive Urgent Care of Indian Wells and its representatives, agents, and subcontractors (included but not limited to adjustors, nurses, and case managers) of the entity that providers arranges for applicable workers compensation or other benefits (hereafter, the workers compensation carrier) all duty authorized representative of my employer (or such other party for whom I have rendered services as necessary and appropriate for the review and disposition of any workers compensation or other similar benefits (hereafter the employer)My protected health information will be used and disclosed for the following purposes only (each purpose listed and described): To insurance carriers for its use in the provision of certain provider quality assessment services, appropriate payment for professional services rendered to EUCIW, to the workers compensation carrier for purposes of reviewing and assessing a treatment plan and otherwise overseeing the claim and employees, as necessary for the review and disposition of any workers compensation claims or similar benefits.This authorization will expire at such time (1) my treatment with the provider concludes, (2) all payments for such treatment has been appropriately made and accounted for, (3) all quality assessment or other operational use of my health information has been made, (4) all information has been disclosed as appropriate to the workers compensation carrier (or other benefits carrier) and/or my employer.I may revoke this authorization in writing at any time by contacting my provider or his/her staff at the following address and telephone number, except to the extent that my provider has taken action in reliance on his authorization:
74-785 Highway 111, Suite 100
Indian Wells, CA 92210
Phone (760) 346-3932
Fax (760) 346-8584

I understand that I may refuse to sign this authorization. If I refuse to sign I understand that my provider will not condition my treatment, payment, and/or enrollment in a health plan or eligibility for benefits (if applicable) or whether I provide authorization for the requested use/disclosure except: (1) if my treatment is related to research, or (2) if health care services are provided to me solely for the purpose of creating protected health information for disclose to a third party.

I understand that here is a potential for information used/disclosed pursuant to this authorization to be disclosed by the recipient of the information and to no longer be protected by federal or state law.

I hereby certify that I have read and understand the provision set forth in this authorization and agree to its terms.
Patient or Guardians Name
First Last
Todays Date
Date Format: MM slash DD slash YYYY

First Name	Last Name	Relationship	Phone Number

EUC Patient Form

Step 1 of 4 - Patient Information

PATIENT INFORMATION - REQUIRED

EMPLOYER AND PRIMARY CARE - REQUIRED

PARENT / GUARDIAN - CONDITIONAL

AUTHORIZATION - REQUIRED