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    Health Care Authorization Form

    Specific AuthorizationsI give permission to Urgent-Care on Wheels/ to verify my insurance, use my address, phone number, and clinical records to contact me with appointment reminders and missed appointments.

    Post my testimonialDisplay patient photographSend me a newsletterSend a birthday card or holiday related cards information about treatment alternatives or other health related information.
    If.Urgent-Care on Wheels/ contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail

    I give Urgent-Care on Wheels/ to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, the doctor will provide a room for these conversations.

    The authorization is requested by.Urgent-Care on Wheels/ for its own use/disclosure of PHI. (Minimum standards apply)
    You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION,Urgent-Care on Wheels/ will not refuse to provide treatment

    Payment Options

    Service Charge : $99 + PPO insurance

    Cash Price : $225

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