Online Registration Form

Patient Registration Form

What Location? *

What Service? *

Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Secondary/Home Phone Number

Email *

Social Security Number

Patient Date of Birth *//

Gender *

Male
Female

Marital Status *

Single
Married
Widowed
Divorced

Ethnicity *

Hispanic or Latino
Not Hispanic or Latino

Race

Reason for Today’s Visit *

Emergency Contact:

Name

Relationship

Phone Number

Insurance:

Primary Insurance *

Policy Number

Group Number

Patient Relationship to Subscriber

Full Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Subscriber’s Date of Birth//

Subscriber’s SSN

Secondary Insurance

Policy Number

Group Number

Relationship to Subscriber *

Self
Spouse
Child

Do you have a primary care physician? *

Patient Notice
If an individual or a patient at any time (regardless of disability, gender, national origin, race, religion, age, color, or of any other legally protected status) becomes loud, aggressive, cusses, or threatens an employee or other individual, they will be asked to leave the premises. We will discharge any patient that has acted in any manner that makes our employees or other patients feel threatened or in danger.

Signature *

Date//

Authorization for Release of Information to Family Members

Patient Name *

First

Last

Date of Birth//

Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.

Consent

I DECLINE any of my information to be released at this time
I AUTHORIZE Qwikcare MD to release my medical and/or billing information to the following individual(s):

1. Name

Relation to Patient

2. Name

Relation to Patient

3. Name

Relation to Patient

Patient Information

Patient Information *

I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient. You have the right to revoke this consent in writing.

Signature *

Date//

Acknowledgement of Provider Standards

Patient Name *

First

Last

Date of Birth//

1. Controlled Substances

Chronic use of benzodiazepines and narcotics will not be managed by this provider for reasons unrelated to end-of-life / end stage disease management. 30 day prescriptions are provided on a case-by-case basis. No prescriptions for controlled substances, including but not limited to benzodiazepines, stimulants, and narcotics will be provided on a first visit.

2. Behavior

Physical and verbal abuse of the staff IS NOT TOLERATED. This includes, but is not limited, to physical and verbal assault. Yelling and swearing at staff will result in immediate dismissal from this provider.

3. Paperwork / Form Completion

Paperwork brought to the office on the same day can be picked up the week following your appointment. It will not be completed at the time of your visit with the exception for school forms for children. If paperwork is needed quickly you may bring it to the office a minimum of 4 days before your appointment for review.
Patient is responsible for filling in out the patient registration packet and fully completing it 15 minutes before their appointment. If paperwork is not fully completed on time, then the appointment will be rescheduled.
Disability examinations are not completed by this provider.
Letters for emotional support animals will not be provided.
Patients that are 10 minutes late to their appointment, and there no appointments available at that time, will be rescheduled for another day.

4. Attendance Policy:

Failure to provide a 24-hour notice of cancellation will result in a $25 Fee that is non-covered by your insurance company. You will bare all Financial Responsibility for this fee. If you have 3 No shows or last-minute Cancelations may result in Dismissal from our practice.

Consent *

I have read, understand and agree to comply with the above stated provider standards.

Signature *

Date//

FINANCIAL POLICY

Today’s Date//

Patient Name *

First

Last

Date of Birth//

SSN

We are committed to providing you with the best possible medical care. If you have medical insurance, we would like to help you receive the maximum allowable benefits. In order to achieve this goal, we will need your assistance and understanding of our financial policies. Please carefully review this information and tick the boxes to agree.
Current insurance cards must be presented to the office at each visit. Any changes to personal information must be given to the office immediately.

ASSIGNMENT: *

I request that payment of authorized insurance, Medicare, and Medicaid benefits be made payable to Front Range Urgent Care, P.C. or Comfort Care Family Practice on my behalf for services furnished to me. This assignment will remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. In the event that my account is turned over to a collection agency, I agree to pay all reasonable costs of collection and understand that I may no longer be a patient at this office.

CO-PAY/COINSURANCE/DEDUCTIBLE: *

I understand that my primary insurance will be billed; billing secondary insurance is a courtesy only and I am ultimately responsible for assigned co-payments, coinsurance and deductible amounts by primary and/or secondary insurance. Tertiary insurance billing remains my responsibility.

RELEASE OF INFORMATION: *

I authorize the holder of medical information about me to release any and all information to Centers for Medicare and Medicaid Services, its agents, my insurance carrier(s), or other entities as needed to determine these benefits or the benefits for my dependents or myself. If I have health insurance coverage under an HMO, I authorize Front Range Urgent Care, P.C. to release information concerning my diagnosis and treatment to my primary care or referring physician after each visit.

REQUESTS FOR INFORMATION: *

Should I receive any requests from my insurance company in regards to my services at this office, I must respond to that correspondence immediately, in order to have the claim processed and paid.

SELF-PAY: *

Self-pay and previous balance amounts are due and payable at the time of service. Insurance co-payments are mandated by your insurance company and MUST be paid at each visit. Certain tests may be performed that require lab analysis, in those cases you will receive a bill from the lab, we do not set their fee schedule or participate in their billing. I agree that if the insurance company denies benefits for any reason, I am responsible for the full amount owed for services provided.

WORKERS’ COMPENSATION: *

I will provide approval/authorization by the Workers’ Compensation carrier at the initial visit. If the claim is deferred, the private medical insurance will be billed. I understand if the claim is denied, I will be responsible for payment in full. If the claim is in litigation, a verification of this from an attorney and/or the Workers’ Compensation carrier will be provided to this office.

Balances Due: *

I understand and agree to pay a returned check charge of $35.00 for each check that is returned for any reason. I agree to pay the amount of the check plus the service charge within 30 days of receipt of notification. Any balances that are sent to our collection agency for non-payment will incur a 30% increase for credit services.

I have been made aware of the privacy policy of Front Range Urgent Care, P.C. and have received (or reviewed or been given the option to receive and review) a copy of the Notice of Privacy Practices. Failure to provide a 24 hour notice of cancellation will result in a $25 fee that is non-covered by your insurance company. You will bear complete financial responsibility for this fee. Repeated missed appointments may result in dismissal from our practice.

Failure to provide a 24 hour notice of cancellation will result in a $25 fee that is non-covered by your insurance company. You will bear complete financial responsibility for this fee. Repeated missed appointments may result in dismissal from our practice. *

I have read and agree to the above statement.

Consent *

I have read and agree to the above information and I, the undersigned/patient, am ultimately responsible for the fees. By signing below, I consent to be contacted by regular mail, by email or by telephone (including a cell phone number) regarding any matter related to the above referenced account by the creditor, its successors or assigns. This consent includes any updated or additional contact information that I may provide and includes contact that employs auto-dialer technology and/or prerecorded messages. Your attending physician may have an ownership interest in one or more Ambulatory Surgery Centers. Please contact office personnel if you have any questions.

Name *

First

Last

Signature *

Date//

Effective 6/6/2019, Comfort Care Family Practice will not prescribe medication for Chronic Pain Management. DEA regulations have made it difficult for primary care provides to manage pain that may require controlled substance prescriptions. Comfort Care Family Practice has primary care providers with the ability to treat many of your medical issues: however, some may require the care of a specialist. Our Providers will determine a course of care and a referral will be sent out. Comfort Care staff will refer you to pain management for your needs. Please note, it is then your responsibility to call that provider, confirm acceptance of your insurance and to make an appointment. When your appointment is made, call us back and we will refill your medication one time to last you through your appointment and up to 2 weeks with pain management. If you miss your appointment or reschedule your appointment with pain management, we will not refill your medication. There are a few requirements for the Colorado Clinic. You need to show up to the appointment 30 minutes prior for paperwork and prescreening. They will create a plan of action on the first visit and will not prescribe medications on the first visit. Patients are required to provide a UA drug screen at the visit. Patients cannot test positive for marijuana or other hard drugs.
Rest assured that Comfort Care Family Practice staff and providers want to help you on your quest to wellness and good health.

Name *

First

Last

Signature

Date//

HEALTH HISTORY QUESTIONNAIRE

Name *

First

Last

Gender

Male
Female

Date of Birth (copy)//

Previous or referring doctor:

Date of last physical exam://

PERSONAL HEALTH HISTORY

List any medical problems that other doctors have diagnosed

Surgeries Details: Year / Reason / Hospital

Other Hospitalizations Details: Year / Reason / Hospital

Have you ever had a blood transfusion?

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

If any, Name the Drug / Strength / Frequency Taken

Allergies to medications

If any, Name the Drug and Reaction You Had:

HEALTH HABITS AND PERSONAL SAFETY
All Questions Contained In This Questionnaire Are Optional And Will Be Kept Strictly Confidential.

Exercise

Sedentary (No exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

Diet

Are you dieting?

If yes, are you on a physician prescribed medical diet?

Number of meals you eat in an average day?

Rank salt intake

High
Medium
Low

Rank fat intake

High
Medium
Low

Caffeine

None
Coffee
Tea
Cola

Number of cups/cans per day?

Alcohol

Do you drink alcohol?

If yes, what kind?

How many drinks per week?

Are you concerned about the amount you drink?

Have you considered stopping?

Have you ever experienced blackouts?

Are you prone to “binge” drinking?

Do you drive after drinking?

Tobacco

Do you use tobacco?

Cigarettes – pks./day?

Chew - #/day?

Pipe - #/day?

Cigars - #/day?

Number of years Or year quit?

Drugs

Do you currently use recreational or street drugs?

Have you ever given yourself street drugs with a needle?

Sex

Are you sexually active?

If yes, are you trying for a pregnancy?

If not trying for a pregnancy list contraceptive or barrier method used:

Any discomfort with intercourse?

Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?

Personal Safety

Do you live alone?

Do you have frequent falls?

Do you have vision or hearing loss?

Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?

FAMILY HEALTH HISTORY

Father

Age

Significant Health Problems

Mother

Age

Significant Health Problems

Sibling

1) Gender

Age

Significant Health Problems

2) Gender

Age

Significant Health Problems (copy)

3) Gender

Age

Significant Health Problems (copy)

Children

1) Gender

Age

Significant Health Problems

2) Gender

Age

Significant Health Problems

3) Gender

Age

Significant Health Problems

Grandmother [Maternal]

Age

Significant Health Problems

Grandfather [Maternal]

Age

Significant Health Problems

Grandmother [Paternal]

Age

Significant Health Problems

Grandfather [Paternal]

Age

Significant Health Problems

MENTAL HEALTH

Is stress a major problem for you?

Do you feel depressed?

Do you panic when stressed?

Do you have problems with eating or your appetite?

Do you cry frequently?

Have you ever attempted suicide?

Have you ever seriously thought about hurting yourself?

Do you have trouble sleeping?

Have you ever been to a counselor?

Women Only

Age at onset of menstruation:

Date of last menstruation://

Period every number of days

Heavy periods, irregularity, spotting, pain, or discharge?

Number of pregnancies

Number of live births

Are you pregnant or breastfeeding?

Have you had a D&C, hysterectomy, or Cesarean?

Any urinary tract, bladder, or kidney infections within the last year?

Any blood in your urine?

Any problems with control of urination?

Any hot flashes or sweating at night?

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Experienced any recent breast tenderness, lumps, or nipple discharge?

Date of last pap and rectal exam?//

Men Only

Do you usually get up to urinate during the night?

If yes, number of times

Do you feel pain or burning with urination?

Any blood in your urine?

Do you feel burning discharge from penis?

Has the force of your urination decreased?

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Do you have any problems emptying your bladder completely?

Any difficulty with erection or ejaculation?

Any testicle pain or swelling?

Date of last prostate and rectal exam?//

Covid vaccines available upon appointment only
Call 719-471-2273 : NO Physician order needed.

COVID testing available TODAY: NO Physician order needed.

To learn more and find out if you're eligible for vaccination click below.

Covid vaccines available upon appointment only Call 719-471-2273 : NO Physician order needed.

COVID testing available TODAY: NO Physician order needed.

To learn more and find out if you're eligible for vaccination click below.

Covid vaccines available upon appointment only
Call 719-471-2273 : NO Physician order needed.