* Required Information

Insurance Information

By signing below, I understand that I am responsible for services that are considered non-covered expenses by my insurer.

Patient Consent and Authorization


I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy reagarding my Protected Health Information. I understand that the information can and will be used to:
  • Conduct, Plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third party payors.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
I understand that I may request in writing that you restrict how my informations is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are required to agree to my requested restrictions, and if agreed, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Consent for Evaluation and/or Treatment

By signing below, I am giving my consent to the practice of Family Urgent Care for evaluation and/or treatment. Once I have been examined, I understand that I will be informed of any medically recommended diagnostic procedures and/or treatments and given the option to accept or decline. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

Contact Information

Please list the person(s) with whom we can discuss your health information.