New Patient Forms

Pharmacy (Location, Crossroads, or Address)

Emergency Contact

Please present your insurance card(s) and your photo ID to the receptionist when you arrive.

Consents for Purposes of Treatment, Payment, HIPAA, Release of Information & HIV Testing

Release of Protected Health Information (PHI)

My "protected health information" (PHI) refers to health information, including my demographic details, collected from me and created or received by my healthcare provider, a health plan, my employer, or a healthcare clearinghouse. This PHI relates to my past, present, or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I authorize the use and/or release of my PHI to EXPRESS MED URGENT CARE PLLC. This authorization shall remain valid as long as I am under their care.

I understand that:

I have the right to inspect or copy the health information I have authorized for use or disclosure.

I have the right to receive a signed copy of this authorization form.

I may request restrictions on how my PHI is used or disclosed for treatment, payment, or healthcare operations.

EXPRESS MED URGENT CARE PLLC is not required to agree to my requested restrictions. However, if they do agree, the restriction is binding.

I may revoke this consent in writing at any time, except when EXPRESS MED URGENT CARE PLLC has already relied on this authorization.

To request restrictions or revoke this consent, I may contact (313) 277-4100.

Notice of Privacy Practices

EXPRESS MED URGENT CARE PLLC’s Notice of Privacy Practices has been provided to me. This notice outlines my rights and EXPRESS MED URGENT CARE PLLC's responsibilities regarding my protected health information (PHI).

I understand that:

EXPRESS MED URGENT CARE PLLC reserves the right to modify its privacy practices.

I can request a revised Notice of Privacy Practices by calling the office.

I consent to the release of my medical records as necessary for my treatment and to obtain payment from my insurance provider.

Consent to Treat and Bill

I consent to and authorize EXPRESS MED URGENT CARE PLLC to provide medical treatment.

I understand that:

I may receive procedures, medications, and treatments deemed necessary for my care.

I have the right to ask questions and refuse treatment at any time.

My healthcare provider will explain my treatment plan and procedures so I can make informed decisions.

Medicine is not an exact science, and my treatment may involve risks and uncertain outcomes.

My provider may prescribe a therapeutic treatment plan, which I agree to follow.

I also authorize:

My insurance benefits are to be paid directly to EXPRESS MED URGENT CARE PLLC for services provided.

EXPRESS MED URGENT CARE PLLC to release necessary medical information to secure payment.

The use of my signature for all insurance submissions.

My financial responsibility for all charges, regardless of whether my insurance covers them.

Human Immunodeficiency Virus (HIV) Testing

I understand that EXPRESS MED URGENT CARE PLLC will perform an HIV test on me if an employee is exposed to my blood or bodily fluids.

I acknowledge that:

My results will be confidential.

My test results may need to be shared with employees providing my care.

Lab Work

I understand that my lab work may be processed by an external laboratory, and I may receive separate billing from them.

If my health plan does not participate with the lab, I will be responsible for the charges.

EXPRESS MED URGENT CARE PLLC will provide me with the name of the lab used.

Copay / Deductible / Coinsurance

EXPRESS MED URGENT CARE PLLC will bill my insurance promptly.

Regardless of insurance coverage, I am financially responsible for:

• Copays
• Deductibles
• Co-insurance
• Out-of-network charges

It is my responsibility to verify whether my insurance plan is in-network with EXPRESS MED URGENT CARE PLLC.

Copays are due at the time of service.

For auto accident or worker’s compensation cases, payment will not be collected before medical evaluation and treatment.

I must provide billing information within three (3) business days, or I will be personally responsible for all charges.

Acknowledgment and Signature

I understand that I should not sign this form unless I fully understand its contents and agree to its terms.

I acknowledge that:

I can ask questions at any time.

I have been provided with necessary explanations regarding my rights and responsibilities.