GUARANTOR INFORMATION (If patient is under 18, or on someone else’s insurance, this is required information)

INSURANCE INFORMATION

INSURED INFORMATION (IF OTHER THAN PATIENT) - ​We will request to scan your ID and Insurance card

COVID - 19 SYMPTOMS CHECK

Have you had any of the following symptoms over the last 21 days?

SOCIAL HISTORY

Do you use/How often do you use?

Drugs

Have you been exposed to

Have you ever had any of the following?

PAST MEDICAL HISTORY & REVIEW OF SYSTEMS

Please check if you have had problems with or are presently complaining of any of the following:

FAMILY HISTORY

HAS ANY MEMBER OF YOUR FAMILY (INCLUDING PARENTS, GRANDPARENTS,AUNTS/UNCLES, CHILDREN, AND SIBLINGS) EVER HAD THE FOLLOWING?

MEDICAL SERVICES CONSENT AND FINANCIAL POLICY

This consent is required by HIPAA, Health Insurance Portability and Accountability Act of 1996 to informyou of your rights for privacy with respect to your health care information.

Consent Related to Privacy Notice:​ I have had a chance to review the Practice Privacy Noticeas part of this registration process. I understand I have the right to request how my protected healthinformation (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, butthis practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it isbound by that agreement. ​HealthCareOnTheGo LLC​ reserves the right to change the privacypractices that are described in the Notice of Privacy Practices. I may obtain a revised Notice ofPrivacy Practices by calling the office number and requesting a revised copy be mailed to me, by accessing ​HealthCareOnTheGo LLC​ website listed above to view the most current version.

Consent for Care​: ​I, with my signature, authorize Health CareOnTheGo, LLC and any employeeworking under the direction of the provider to provide medical care for me, or to this patient for which I amthe legal guardian. This medical care may include services and supplies related to my health (or theidentified person) and may include (but not limited to preventative, diagnostic, therapeutic, rehabilitative,maintenance, palliative care, counselin​g​, assessment or review of physical or mental status​/​function ofthe body and the sale or dispensing of drugs, devices, equipment or other items required and inaccordance with a prescription. This consent includes contact and discussion with other health careprofessionals for care and treatment.​

RELEASE OF INFORMATION

I hereby give permission to the person(s) listed below to receive information about thecare of the above named patient.

Financial Policy:​​ We appreciate you choosing us for your healthcare. ​W​e will adhere to the followingfinancial policy to consistently deliver high quality care and services. The patient/responsible partyassumes responsibility to ensure that the financial obligation is fulfilled for the health care servicesrendered. I understand that I am responsible for all payments at the time of service and an itemizedreceipt can be provided.​ I certify I have read and understand the foregoing, have had theopportunity to ask questions and have them answered and accept all conditions and terms. Iagree to pay all charges for office visits, labs and medications which I may be legallyresponsible for including, but not limited to health insurance deductibles, co-payments, andnon-covered. I also agree in the event my account must be placed with an attorney or collectionagency to obtain payment, I will pay the reasonable attorneys' fees and other collection costsincurred by ​HealthCareOnTheGo LLC​.

HIPAA AUTHORIZATION FORM

I , hereby authorize the use or disclosure of my protected health information as described below:

1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

​HealthCareOnTheGo LLC​ is authorized to disclose the following protected health information to

2. DESCRIPTION OF INFORMATION TO BE DISCLOSED

The health information that may be disclosed is:

• Medical records
• Covid Results/Labs

All past, present, and future periods of health care information may be shared.

3. PURPOSE OF THE USE OR DISCLOSURE

The purpose of this use or disclosure is .

4. VALIDITY OF AUTHORIZATION FORM

This Authorization Form is valid beginning on 01/01/2021-12/31/2021

5. ACKNOWLEDGMENT

I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.