Watkinsville Urgent Care New Patient Form

Past Medical History

Family History

Watkinsville Urgent Care Financial Policy

Thank you for choosing Watkinsville Urgent Care (WatUC) to care for you and your family today. Please understand that payment of your bill ensures the practice remains financially healthy and stable so that we may continue to provide care for future patients. If you have any questions regarding this financial policy, please do not hesitate to speak with management.

1. INSURANCE COMPANY: WatUC is currently in-network with most commercial insurance plans. It is the responsibility of the patient, however, to determine if the doctor you are seeing is in-network with your insurance company. Be sure to contact your insurance company to verify that we are in network with your current policy. We depend on you to provide us with correct insurance information so that we may file your claims appropriately. If you provide us with incorrect information and your insurance company denies payment you will be responsible for all of the resulting charges.
2. PAYMENTS: You are financially responsible for the cost of your care. If you have a copayment due, your insurance company requires us to collect it at the time of service. This is due from the patient or from the parent/guardian, in the case of a minor.
3. PROOF OF INSURANCE: WatUC must obtain a copy of your driver's license and current valid insurance information. If you are unwilling or unable to provide your ID information or current insurance information, your visit shall be paid in full by you at the time services are rendered.
4. NEWBORN INSURANCE: When a child is born, we understand that it may take time to have that new bundle of joy added to your insurance policy. Please contact the office as soon as your child’s insurance is activated. After 30 days you will be responsible for any balances that are not paid by insurance.
5. CLAIMS SUBMISSIONS: We will submit your claims or assist you in any way we reasonably can to help get your claims paid. Please be advised that this is a courtesy provided by WatUC rather than a responsibility. Your insurance company may need you to supply certain information to them directly. It is your responsibility to comply with their request.
6. COVERAGE CHANGES: If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. In the event that valid information is not provided to our office in a timely manner, WatUC will not be held to timely filing requirements by your insurance company.
7. DIVORCE AND SEPARATION ISSUES: In the case of a divorce or separation, it is imperative that we be notified as to who has primary responsibility, including financial responsibility, for the care of your children. The person with primary responsibility for the children will be responsible for payment of all charges not paid by insurance unless we are notified otherwise. Proof of responsibility may be requested in the form of copies of the divorce paperwork. It is the parents’ responsibility to work together to ensure that all charges not paid by insurance are paid in a timely manner. We will not get involved in how these charges are allocated between parents/guardians.
8. RE-BILLING FEES: The policy of WatUC is to provide your first billing statement as a courtesy. After the first billing cycle, if payment has not been made in full, a re-billing fee may be applied to the account in the amount of $10. This re-billing fee will be added to each statement thereafter if no payments are received.
9. COLLECTIONS: Delinquent accounts that are greater than $60 and 60 days past due will automatically be sent to the first phase of our collections process. If the balance remains unpaid, your family may be permanently dismissed from the practice and the balance turned over to a collection agency. If this occurs, an additional fee of up to $100 may be added to your account. This will not be covered by insurance. You will be responsible for this cost.
10. STORAGE OF INFORMATION: By default, WatUC does not store payment information such as Credit Card Numbers or Bank Account numbers. When making payments through our online system, you may be given the option to save payment information on file with the credit card processor. This information is stored with the processor and is not accessible by WatUC. This is done in an effort to maintain best practices with regards to handling financial information. This feature is offered to simplify payments in the future and is optional.
11. OTHER SERVICES:
    - Immunization records will be prepared within 48 hours and are at no charge to you.
    - Requests for medical records and specialized reports will usually be completed within 5 days and will incur a charge of $25, or as allowed by law. Some insurance companies may not cover this expense. In this case, it is the responsibility of the parent/guardian to pay for this charge.

Rev 11/13/2024

Financial Responsibility

With the exception of Copays and Self pay which are due at the Time of Service, who is Financially Responsible for any bills that may occur due to deductibles, coinsurance, or balances that insurance may deem to be the patient's responsibility?

Please have your insurance card and drivers license ready when you arrive at our facility.

By submitting this form, I attest that the above information is accurate and truthful to the best of my ability. I acknowledge that some information may require additional explanation or verification. I will contact PrimeTime Urgent Care in a timely fashion if any of the above information requires change or modification. I acknowledge that I have been provided, and have reviewed, and understand the above financial policy.