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  • If you were automatically directed to this form after submitting the Registration Form, then your Registration Form has been submitted!  Thank you!

  • Insurance Cards

    We are required to obtain a current copy of all insurance cards annually, or when they change. To speed up the check-in process at your next appointment, please upload a current copy of the FRONT and BACK of all insurance cards.
  • Para ver este formulario en español, haga clic en el menú desplegable en la esquina superior derecha.

  • It is crucial to keep your medical records, personal information, and insurance information up to date.  Providing complete and accurate information will benefit you, as a patient, because it makes billing flow more accurately.

     

    We, like any other medical facility, need to request your insurance card and ID along with updated contact information to ensure our records are accurate and will need to update your records annually. Filling out the patient paperwork in its entirety is vital in preventing errors and will decrease the risk of a medical visit denial for payment, in turn making it possibly your responsibility for payment. If you have moved, changed phone numbers or insurances please notify our clinic so your billing/chart information is correct.

     

    A physical copy of an active insurance card is needed annually. I understand if UCHC does not have a current copy an active insurance card, I may be responsible for the full bill and may be required to work out a payment arrangement.  I understand that I may be charged for all medical services which may include doctor fees, labs, tests, and immunizations/vaccines.  I understand that I may be fully responsible for any referrals to specialists.  I understand that I will be marked as ‘self pay’ until an active insurance card is obtained and entered into the Medical Record Chart.

     

    If you get a new insurance card, please bring it in so we can make sure it’s current in your records, even if it is the same policy, for the billing information may have changed.  If you are tech savvy, feel free to use our easy upload form and upload it electronically.  Upload forms are available on our website at https://uchcaz.org.

     

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  • EXAMPLE - Upload a clear and legible copy of both sides.

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  • By signing, you agree your electronic signature is the legal equivalent to your manual/handwritten signature. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

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