INSURANCE Patient information form: Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * Gender * options Male Female Insurance carrier example: fidelis or oxford. * Insurance ID # * Upload the FRONT of your insurance card here * FileField; MaxSize=5000KB; Multiple; addText=Upload_Your_Files Upload the BACK of your insurance card here * FileField; MaxSize=5000KB; Multiple; addText=Upload_Your_Files I consent and agree that: In the event that I have a copay or did not meet my deductible, I will provide a credit card below. I will Include card number, cvv, exp. I consent and agree that all copays will be automatically charged at time of visit. All unmet deductibles will be billed via mail. * Please note a 3% processing fee will be charged for all credit card payments. To avoid this fee you can pay via quick pay (reach out to the office for details). For any questions regarding insurance and/or deductible status please email billing@bleugloveconcierge.com. I consent and agree I consent and agree Name as it appears on Card * CC # * Expiration # * Include month and year CVV * If the reason for your visit includes covid-19 PCR testing for a flight, please provide passport number below. Any Allergies? * Do you have any long term health issues or Medical History? * If the answer to this question is yes please provide a brief description below Please list any long term medications that you are currently taking and their dosage * For patients 0-18 years please provide height and weight * If you are 19 years or older, write N/A By checking the box below I consent to the office of Adina Erez the right to release my medical records and test results to an insurance company or third party payer and their agents for the purpose of determining eligibility, benefits and obtaining payments for the services provided for me by this office. In addition, I understand that I am responsible for and will pay the remaining balance not covered by insurance companies, governmental agencies, or third party payers. Lastly, I acknowledge that all bills will be mailed to me by "Community Urgent Care." * I consent and agree I consent and agree Thank you, your form has been submitted. For any questions kindly text or WhatsApp our office at 917-334-4134 NON-INSURANCE Patient information form: Reason for visit * Any Allergies? * Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth Gender * options Male Female If the reason for your visit includes covid-19 PCR testing for a flight, please provide passport number below. Visit Fee Payment is due at time of visit. Acceptable payment methods include: - Cash - Credit card: - Quick Pay, Venmo, Zelle COVID-19 Tests: $50.00 Sick Visits: $65 Name as it appears on Card * CC # * Expiration # * Include month and year CVV * By checking the box below I consent to the office of Adina Erez the right to release my medical records and test results to an insurance company or third party payer and their agents for the purpose of determining eligibility, benefits and obtaining payments for the services provided for me by this office. In addition, I understand that I am responsible for and will pay the remaining balance not covered by insurance companies, governmental agencies, or third party payers. Lastly, I acknowledge that all bills will be mailed to me by "Community Urgent Care." * I consent and agree I consent and agree Thank you! Your response has been recorded
