UrgentPoint Living Telemedicine
Email address *
Demographic Information
Last Name *
First Name *
Date of Birth *
Phone Number *
Insurance Carrier *
Insurance Policy/Member ID# *
Policy Holder Name
What facility are you located at? *
Are you a detox client? *
Do you need refills on any medications? *
What medications need refills?
For Call-In Prescriptions:
Please provide the phone number and address of the pharmacy you want your prescriptions called into.
Lab Results
Are you waiting for lab results? *
What results are you waiting for?
Your Telemedicine Visit
How can we help you today? *
Please write a short description of what issues you are experiencing and what we can do for you. The doctor will be informed of this so the more descriptive you are the better prepared the doctor will be to see you!
Telemedicine Agreement
Agreement of Service *
By clicking "I Agree" you accept that this telemedicine visit was requested by you to receive medical services from UrgentPoint. You authorize the release of any medical information necessary to process the claim and request that payment of all benefits be made to the undersigned physician or supplier for telemedicine services described below. You authorize the use of this electronic signature on all insurance submissions. You also authorize UrgentPoint to bill your insurance for this visit in agreement with our terms of service.
Electronic Signature *
By e-signing below, you verify the information above is correct and true. (please type full name)
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of UrgentPoint. Report Abuse