08/27/2024 Back to School Sports Physicals & Wellness Checks (Klahowya Secondary School)

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* 1. What is your preferred appointment time block?

9:00 am

9:15 am

9:30 am

9:45 am

10:00 am

10:15 am

10:30 am

10:45 am

11:00 am

11:15 am

11:30 am

11:45 am

12:00 pm

12:15 pm

12:30 pm

12:45 pm

1:00 pm

1:15 pm

1:30 pm

1:45 pm

2:00 pm

2:15 pm

2:30 pm

2:45 pm

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* 2. Patient Last Name

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* 3. Patient First Name

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* 4. Patient Date of Birth

Date / Time

Date

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* 5. Patient Sex at Birth

Male

Female

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* 6. Address

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Country

Phone Number *

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* 7. Consent to Call

Yes

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* 8. Consent to Text Message?

Yes

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* 9. Insurance

Primary Insurance Name

ID Number

Guarantor (person who is responsible for the insurance) Name and Date of Birth

Insurance mailing address for claims (address on back of card, not your address)

Secondary Insurance Name

ID Number

Guarantor (person who is responsible for the insurance) Name and Date of Birth

Insurance mailing address for claims (address on back of card, not your address)

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* 10. If uninsured and you would like to be contacted about how to apply for slide scale or insurance, please check the box.

Contact me about Sliding Scale or to set up an appointment with an insurance navigator

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* 11. Billing Authorization
Please read the statements below. Check each box (last box for Medicare recipients only) Enter your name and date to provide authorization.

I accept financial responsibility for all my professional services and/or supplies. Payment for service is due at the time rendered unless arrangements have been made

I authorize my insurance to pay PCHS directly. I am financially responsible for any balance due. I authorize PCHS or the insurance company to release any information for claims unless specifically limited by me in writing.

(Medicare Recipients Only) I request that payment for authorized Medicare benefits be made on behalf of Peninsula Community Health Services for any services provided to me.

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* 12. Full Name of Parent or Guardian

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* 13. Date

Today's Date

Date

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* 14. Check the box below if you would like to receive a copy of the Patient Rights & Responsibilities

Mail me a copy of the Rights & Responsibilities

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* 15. Confirm you have filled out the online forms listed below (Forms are required for appointment)

English & Spanish Forms | Formularios en inglés y español

I have filled out the online forms

08/27/2024 Back to School Sports Physicals & Wellness Checks (Klahowya Secondary School)

Question Title

* 1. What is your preferred appointment time block?

Question Title

* 2. Patient Last Name

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* 3. Patient First Name

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* 4. Patient Date of Birth

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* 5. Patient Sex at Birth

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* 6. Address

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* 7. Consent to Call

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* 8. Consent to Text Message?

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* 9. Insurance

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* 10. If uninsured and you would like to be contacted about how to apply for slide scale or insurance, please check the box.

Question Title

* 11. Billing AuthorizationPlease read the statements below. Check each box (last box for Medicare recipients only) Enter your name and date to provide authorization.

Question Title

* 12. Full Name of Parent or Guardian

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* 13. Date

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* 14. Check the box below if you would like to receive a copy of the Patient Rights & Responsibilities

Question Title

* 15. Confirm you have filled out the online forms listed below (Forms are required for appointment)English & Spanish Forms | Formularios en inglés y español

* 11. Billing Authorization
Please read the statements below. Check each box (last box for Medicare recipients only) Enter your name and date to provide authorization.

* 15. Confirm you have filled out the online forms listed below (Forms are required for appointment)

English & Spanish Forms | Formularios en inglés y español