CareForceMD

No Symptoms

Fever or Chills

Cough

Sore Throat

Shortness of Breath or Difficulty Breathing

Congestion or Runny Nose

Muscle or Body Aches

Headache

Pains

Fatigue

Pregnant

New loss of taste or smell

Nausea or Vomiting

Diarrhea

Yes	No	Anyone who is known to have laboratory-confirmed COVID-19? OR Anyone who has any symptoms consistent with COVID-19?
Yes	No	Are you isolating or quarantining because you may have been exposed to a person with COVID-19 OR are worried that you may be sick with COVID-19?
Yes	No	Are you currently waiting on the results of a COVID-19 test?

Yes

No

Have you had your annual recommended diabetic retinopathy screen?

I am requesting the release of the following medical record: *

Consent for Treatment: I consent to CareForceMD and give consent to my physician, the employees, and all other persons caring for me, to treat me in ways they judge are beneficial to me. I understand that this care may include physical examinations, diagnostic procedures, blood test, and medical/surgical treatment deemed necessary by my attending physician, his/her associates or designees. I certify that no guarantees have been made to me regarding the outcome of this care. The use of virtual medical technology may be included in the diagnostic processes of care.
Authorization for Release of Medical Information/Assignments of Benefits: I give permission to CareForceMD and physician providers to release medical information to insurance carriers or to any government charged with fiscal responsibility for the payment of medical services rendered; and, I hereby authorize the clinic and physicians benefits otherwise payable to me, directly to CareForceMD and/or the physician provider. I consent to having any monies, received by the provider of services, on my behalf, to be applied to my outstanding account. I also assume full responsibility for payment of any charges for the medical services provided.
Medicare Screening Form (MSP): I certify that the information given is true, correct, and accurate.
Right to Participate In and Direct Health Care Decisions: Federal law requires that you be given the following information: You have the right to have medical treatment options clearly explained to you. You also have the right to decide what treatment you will receive and what treatment you will decline. In addition, you have the right to formulate an advanced directive (living will, appointment of an agent or durable power of attorney for health care) regarding treatment. An advanced directive is a written statement which relates to the provision of care when you are incapacitated. Through a living will, you may direct what treatment you want or do not want if you become terminally ill. You may also appoint an agent to make medical decisions for when you are not terminally ill but incapacitated, either through a durable power of attorney or the appointment of an agent for health care. Copies of the living will form and appointment of agent form are available upon request, and a member of our Spiritual Care Department is available to discuss these advance directives with you. Please note that your right to direct treatment does not mean that a physician or clinic must follow your instruction if they believe it is seriously wrong. They may notify you that they are unwilling to abide by your instruction. If you wish to stand by your instruction, it is your responsibility to find a physician that will agree to follow your instruction.
Personal Valuables: I understand that CareForceMD will not be responsible for personal effects (including money, eyeglasses, dentures, jewelry, and documents) retained in my possession, or any articles belonging to me. I accept full responsibility for keeping such items in my possession. I understand that belongings left behind will be retained for 14 days from the date of discharge.
Responsibilities for Education & Safety: I have been informed of my role in helping to facilitate the safe delivery of care. This means that I am responsible for providing accurate and complete information to CareForceMD staff and my provider. I will report unexpected changes in condition, asking as many questions as needed to assure my understanding, safety, and comfort level. I will follow the instructions, accepting consequences if instructions are not followed. I will follow CareForceMD rules and regulations and act with consideration and respect towards CareForceMD staff, property, and other patients.
Your Opinion Matters to Us: Because we care, we have engaged a survey firm to contact a random sample of our patients. Within a couple of days after returning home, a CareForceMD representative will inquire about your experience at CareForceMD may contact you or a member of your family. We will use your feedback for quality assurance purposes and to improve our performance and service. Please understand that your participation is optional.
Consent for Contact: You agree that CareForceMD, including our business associates , may contact you by telephone at any telephone number provided by you or associated with your record, including your cell phone number, which could result in charges to you. We may also contact you by sending text messages, emails and/or direct mail, using the contact information you provide. Methods of contact may include using a pre-recorded/artificial voice messages and/or use of an automatic dialing service, as applicable.
Consent for receiving information through portal.careportmd.com: You consent to receiving and sending information securely through our portal. We will provide you with login credentials that you can use to access your results and to provide any information to CareForceMD.

Authorization should be signed by the patient, or the nearest relative if the patient is a minor, physically unable to sign or mentally incompetent. If yes, complete the following:

Check here if patient is a minor.

Check here if patient is unable to sign or mentally incompetent.

I have read and agree to the terms below *

I understand and agree that all CareForceMD claims go through the patient's insurance.
I agree and understand that in the absence of any insurance coverage and of proof of US residency such as when using a foreign passport for identification, patient is required to pay for the cost of the test, out of pocket.
I understand and agree to arrive & check-in at the appointment location, at least 15 minutes before the scheduled time.
I understand and agree to physically bring appropriate identification and insurance documents (when applicable).

First Name *

Last Name *

Address line 1 *

Address line 2

City *

State *

Zip Code *

Phone * Format: (302) 123-1234

+1

Date of Birth *

Gender *

Race *

Ethnicity *

Please specify the Other Race *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Relationship to patient *

I understand that I may revoke at any time this authorization by providing a written request and submitting it to: *

CareForceMD 1 Innovative Way Suite 304 Newark DE 19711

This information may include sensitive information. *

This release of information is valid from this day until ( enter a date if you would like to specify an end date for this authorization )

I understand and agree that by typing my name here, I am electronically signing this form. *

Authorized Person Name *

Speedy Care

Selected Location: (Change Location)

Uptown Discount Drugs Pharmacy

Requested Appointment Date & Time *

Patient Information

Symptoms / Reason for visit *

Past Medical History

Release of Medical documents

Patient Details