Credit Card Authorization for Outstanding Balances

We respectfully request that you please take a moment and review our policy for credit card authorization for any outstanding balances determined by your health plan to be your responsibility and the reasons for this policy. Please note that the Credit Card Authorization for Outstanding Balances agreement is meant to supplement and be consistent with the General Patient Agreement. Our policy: It is our policy to request every patient or parent/legal guardian to provide us with a credit card or debit card authorization for any outstanding balances for services rendered and determined to be the responsibility of the patient or parent/legal guardian. We will put a $5 authorization hold on your credit card at the time of your visit. You will receive an explanation of benefits (EOB) via email or mail from your insurance company outlining what services were covered and how much remains as patient responsibility. We will also receive a copy of the EOB and will charge your credit card on file the amount due as indicated within 5-7 days of receipt of the EOB. If there is no balance due, your card will not be charged. A copy of the credit card receipt will be emailed or mailed to you. If your credit card is declined, we will call you to let you know. If we receive no response to a declined payment, a $35 declined payment fee will be applied. If you do not respond within 10 days, your account will be sent to collections with Pioneer Capital Solutions, Inc. The aforementioned policy of requesting every patient or parent/legal guardian to provide us with a credit card authorization does not apply to patients with health coverage provided by Medicaid or self-pay patients who pay for services at the time of the visit. In the event you refuse to have a credit card placed on file and authorize Priority Care Clinics, LLC, to charge that credit card for any and all amounts not covered by the patient’s insurer and/or you have an outstanding balance, WE MAY REFUSE TO TREAT AND/OR PROVIDE YOU WITH MEDICAL CARE, (as we are a privately established business), unless such refusal is otherwise prohibited by State and/or Federal law and/or the provisions set forth in any applicable insurance policy and/or contract. Acknowledgement of Payment Responsibility & Authorization to charge credit card: I hereby understand that the Credit Card Authorization for Outstanding Balances agreement is meant to supplement and be consistent with the New Patient Agreement that I entered into with Priority Care Clinics, LLC. I hereby state that I am personally responsible for the payment of my own and/or my dependent’s medical care. I hereby willingly authorize Priority Care Clinics, LLC, to charge my credit card for any and all medical services rendered to me and/or my dependent/child that are not covered by my own and/or my child/dependent’s health insurance policy. I hereby willingly provide my credit card information to Priority Care Clinics, LLC as set forth below. I understand that I am personally responsible for the payment of treatment, medical services, and medical supplies including vaccines provided to me and/or my child/dependent by Priority Care Clinics, LLC.

I further understand that the payments for which I may be personally responsible include, but are not limited to, co-payment(s), deductible(s), co-insurance, and/or any outstanding balances or fees that are not covered by my own and/or my child/dependent’s health insurance policy.

I, ___________________________, hereby willingly authorize Priority Care Clinics, LLC, to charge my credit card for the balance of charges not paid by my insurer. I understand that generally I will be notified via email or regular mail as to the amount charged on my credit card to allow me to check my credit card statement to be sure that it is right. __________ (Initial) Email address for credit card receipt: ________________________________________________________

I hereby willingly authorize Priority Care Clinics, LLC, to place a $5 authorization only hold on my credit card. __________ (Initial)

I am aware that, if my insurer pays Priority Care Clinics, LLC, after my credit card has been charged, I will be promptly reimbursed any credit due. In the alternative, if I so desire, I can request that Priority Care Clinics, LLC, retain all or some part of that amount as a credit on my account for my next visit. If I have any questions, I can contact Priority Care Clinics, LLC, at billing@prioritycareclinics.com

I affirm that the statements contained herein are true to the best of my knowledge; that I authorize to incur this charge to my credit card, and I thereby authorize future credit card charges necessary to pay outstanding balance as stated above.

Print Patient’s Name: ______________________________________Signature of Cardholder:_____________________________________ Today’s Date:________________________

PATIENT LABEL HERE

PRIVACY POLICY/HIPAA

Priority Care Clinics, LLC, Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our office may change. If we change our notice, you may obtain a revised copy from our front desk receptionist.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this consent in writing, except where w e have already made disclosures in reliance on your prior consent. You also allow our office to contact you by phone or by mail to provide balance information, information about treatment alternatives, or other health benefits and services that may be of interest to you.

I, ______________________________, give permission for Priority Care Clinics to discuss my care, appointment visits, and financial information with the following person(s):

______________________________ __________________________ ________________

Name Relationship Date of Birth

______________________________ __________________________ ________________

Name Relationship Date of Birth

______________________________ __________________________ ________________

Name Relationship Date of Birth

⃝ None

Primary Care Physician: ________________________________ Telephone #____________________

Specialist: ___________________________________________ Telephone # ___________________

In case of emergency, I give permission to Priority Care Clinics to release my health information to a health care facility for further testing and/or treatment. (Please Check One) Yes ⃝ No

_________________________________________________ __________________________

Patient/Guardian Signature Date

PATIENT LABEL HERE

First Name:

Middle Initial: Last Name:

Date of Birth: Gender:

Social Security #:

Patient Home Address: City, State, Zip:

Home #: Cell #: Okay to leave a message? _____ Yes _____ No

Email Address: How did you hear about our facility? Emergency Contact:

Relationship: Contact #:

Legal Guardian (if under 18)

Relationship: Contact #:

Is this due to a work-related injury: ____ Yes ____ No

Is this due to an auto accident? _____ Yes _____ No

Date of Accident or Injury:

Primary Insurance Name

Policy Holders Relationship to Patient: (Please Circle One) Self Spouse Parent Legal Guardian Other Subscriber DOB: ____________ Social Security #_____________

Secondary Insurance Name Policy Holders Relationship to Patient: (Please Circle One) Self Spouse Parent Legal Guardian Subscriber DOB: ____________ Social Security #_____________

Pharmacy Name & Address:

PATIENT LABEL HERE

Patient Medical History

ALLERGIES REACTION

Are you allergic or sensitive to any of the following? Latex ⃝ Iodine Adhesive Tape

CURRENT MEDICATIONS DOSE HOW OFTEN REASON FOR MEDICATION

MEDICAL HISTORY (CHECK ANY CONDITIONS WHICH YOU HAVE BEEN OR ARE CURRENTLY BEING TREATED FOR)

⃝ Alcoholism ⃝ Asthma ⃝ Anemia ⃝ Arthritis ⃝ Anxiety ⃝ Coronary Artery Disease ⃝ Depression ⃝ Cancer(TYPE) ____________ ⃝ Diabetes (TYPE) ____ GERD ⃝ Heart Disease ⃝ High Cholesterol ⃝ Heart Attack ⃝ Thyroid Disease (HYPO / HYPER) ⃝ High Blood Pressure ⃝ Ulcerative Colitis/Crohn’s disease ⃝ Kidney Disease

I certify that to the best of my knowledge, the contents of this medical history are true and accurate. I authorize Priority Care Clinics, LLC, to enter this information into my electronic chart for use in my medical care or as needed for my insurance carrier or other entity that might request my information.

Patient Name (Print): ___________________________________ Date: _______________________

Patient/Guardian Signature: _____________________________________________________________

SURGICAL HISTORY DATE

FAMILY HISTORY Relationship (Mother, Father, Sibling, Grandparent)

⃝ Cancer Type:

⃝ Anxiety/Depression

⃝ Diabetes Type:

⃝ Heart Disease

⃝ High Blood Pressure

⃝ High Cholesterol

⃝ Kidney Disease

⃝ Thyroid Disease

SOCIALL HISTORY (CIRCLE ONE)

Marital status: Single / Married / Divorced / Widowed Employment: FT / PT / Unemployed / Student Sexually Active: YES / NO Tobacco Use: YES / NO / FORMER Alcohol Use: Social / Daily / Never Drug Use: NO / Marijuana / Cocaine / Other: ___________________

PATIENT LABEL HERE

REASON FOR YOUR VISIT TODAY: _______________________________________________________________________

Please check off any symptoms you are experiencing TODAY ONLY! GENERAL ENT Eye Chest GI GU

NONE NONE NONE NONE NONE NONE Fever Sore throat Double vision Cough Abdominal pain Painful urination Weight gain Nasal drain Blurred vision Wheezing Nausea Frequency Weight loss Sinus pain Eye redness(L/R) Trouble breathing Vomiting Blood in urine Fatigue Congestion Eye pain(L/R) Chest pain Diarrhea Difficult urination Sleep disturb Facial pain Palpitations Black stools Flank pain

Ear pain (L/R) Fainting Bloody stools Incontinence NEURO SKIN MUS/SKEL HEMATO ENDO ALLERG/IMMUN NONE NONE NONE NONE NONE NONE Headache Rash Back pain Bruise easily Inc. appetite Seasonal allergies Trouble walking Itching Neck pain Abnl bleeding Inc. thirst TB/ HEP Blackout Swelling Joint pain Anemia Always hot HIV + Loss strength Stiffness Immunodeficiency Diff speech Knee pain Seizure Shoulder pain Loss sensation Arthritis Confusion Orthopedic disease ARE YOU A CURRENT SMOKER? YES / NO

PSYCH SEXUAL/GENITALIA NONE NONE DATE OF LAST MESNSTRUAL CYCLE: _____________ Depression Abnormal genital discharge Anxiety Abnormal genital bleeding Suicidal Homicidal thoughts

BELOW FOR STAFF USE ONLY____________________________________________________________________________________

BP PULSE RESPIRATIONS TEMP

02%

HEIGHT WEIGHT

***ALLERGIES** CURRENT MEDICATIONS CHIEF COMPLAINT :_______________ _________________________ ______________________ ____________________________

_________________________ ______________________ ____________________________

_________________________ ______________________ ____________________________

_________________________

_________________________

Visual acuity R L B

CORRECTED? COLOR V:

UA RESULTS:

BLD:

UBG:

BIL:

PRO:

NIT:

KET:

GLU:

Ph:

SG:

LEU:

HCG:

PATIENT LABEL HERE