Call Us:

215-376-3339

Visit Us:

15200 Bustleton Ave
Philadelphia, PA 19116

Check In

Patient Information

Reason for Visit
Payment
Consent for Routine Examination and Treatment
Please read our terms carefully and agree to the terms during your check-in process so that we may proceed with the care and treatment at Medex Urgent Care. If you need interpreter services, please notify a staff member.

Consent for Routine Examination and Treatment

You agree to let the provider(s) examining and treating you at Medex Urgent Care make any necessary or recommended decisions about your care during your visit. This may include minor procedures, special tests, administration of medications, imaging studies or other treatment and diagnostic modalities. You also consent to being treated by the provider(s) who are part of Medex Urgent Care’s medical staff, even if they aren’t directly employed by Medex Urgent Care. This is because Medex Urgent Care reserves the option to function as a teaching facility that trains medical professionals. Your care team might include resident physicians or students still in training. Finally, you acknowledge that medicine isn’tperfect, and there are no guarantees about the outcome of your examination or treatment.

Assignment of Benefits
I understand that by agreeing to these terms, I am allowing Medex Urgent Care (and potentially any provider involved in your treatment) to access your health insurance benefits to cover your stay and treatment. I also agree to receive communication from Medex Urgent Care (and potentially collection agencies) about my bill. This communication may include phone calls (including mobile phones), voicemail messages, text messages, and emails. They may use automated systems to deliver these messages.

Financial Agreement
If you’re choosing to pay with your health insurance, here’swhat you need to know: I request that payment and authorized insurance benefits, including Medicare, be made on my behalf for any professional medical services provided to me at Medex Urgent Care. I acknowledge that I have provided my insurance information today and authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related professional services by Medex Urgent Care to the Health Care Financial Administration, my insurance company or other entity upon request to secure payment of my benefits. I understand that I am financially responsible to Medex Urgent Care for any charges not covered by health care insurance. It is my responsibility to notify Medex Urgent Care of any changes in my health care coverage within 7 days of such a change. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I understand that I am responsible for the entire bill including any unpaid balance of the professional services as determinedby Medex Urgent Care and / or if my health care insurer should submit a claim or any part of the claim for payment or apply to my co-pay, deductible or coverage limitations.To help you pay your bill, Medex Urgent Care may appeal denied insurance claims or take other steps on your behalf. This may involve you signing documents to allow them to seek full payment from your insurance company, other responsible parties, or patient assistance programs for medication or devices. If you’re choosing to self-pay, here’swhat you need to know: You’ll be responsible for the cost of the services provided by Medex Urgent Care. We require payment upfront before you receive any treatment. Your insurance will not be billed for this visit. If you later decide to seek reimbursement from your insurance company, you can submit our receipt to them. However, Medex Urgent Care won’t be involved in any disputes with your insurer regarding the amount they reimburse you.

Lien and Right of Subrogation
If you are considering legal action against someone responsible for your illness or injury, Medex Urgent Care may place a lien on any settlement you receive. This lienrepresents the amount you owe for your treatment, minus any payments already made by insurance or other sources.Lawyers working on your case will be required to pay Medex Urgent Care from the settlement funds before giving you any money. In addition, Medex Urgent Care may take over your right to recover money from the person responsible for your injury (subrogation). You agree to cooperate with them to protect this right.

Personal Valuables
Medex Urgent Care is not responsible for lost or damaged money, valuables, or other belongings you bring with you. This includes things like cash, jewelry, electronics, glasses, dentures, and hearing aids. There may be a safe available for valuables, or staff who can hold onto things for you. Please ask about these options if you’re concerned about your belongings.

Notification of Caregiver(s)
If you designate someone as your caregiver, you are allowing Medex Urgent Care to share information about your care with them after you leave. A caregiver is someone close to you who will help you recover at home.

Notification of Stay
Medex Urgent Care may try to inform your primary care physician about your visit as a courtesy, but they may not always be successful due to privacy regulations or time constraints.

Use of Images
Medex Urgent Care may sometimes take videos or pictures of specific parts of your body to help assess your condition or for educational purposes. This would only be done with your permission and would not involve filming your entire body. They may also use audio and video monitoring cameras in common areas of the facility for your safety.Finally, Medex Urgent Care may offer consultations remotely using phone or video calls (telemedicine). You can choose to have an in-person visit instead if you prefer.All your patient rights, including those related to complaints, still apply to audio/video recording, monitoring, and telemedicine services.

Medicare Patients
I have read the above and fully understand its content. I certify that the information given by me in applying for payment under Title IVIII of the Social Security Act is correct.