Care Today

  • Home
  • COVID-19 Info
  • Medical Services
  • Occ Med
  • Work Comp
  • Wellness Screens
  • Medical Service Network
  • Locations
  • Contact Us
  • Patient Portal
  • Appointment
  • TeleMedicine
  • Patient Enrollment

Care Today

  • Home
  • COVID-19 Info
  • Medical Services
  • Occ Med
  • Work Comp
  • Wellness Screens
  • Medical Service Network
  • Locations
  • Contact Us
  • Patient Portal
  • Appointment
  • TeleMedicine
  • Patient Enrollment

Patient Enrollment

Please complete the enrollment information
*
*
*
*
*
*
*
*
*
Next Page
*
*
*
*
*
*
*
Prior Page
Next Page
*
*
*
*
Prior Page
Next Page
*
*
*
*
*
*
Prior Page
Next Page
*
*
*
*
*
*
*
Prior Page
Next Page
*
*
*
*
*
Prior Page
Next Page

I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examination, and treatment.  I hereby assign, transfer, and set over to Care Today Clinic all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy.

I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization.

I understand that I am financially responsible for all charges whether or not they are covered by insurance.  

*
*
*
*
Prior Page
Next Page
  • Care Today

© 2014, Care Today Urgent Health

Opulus Theme | Powered by WordPress