Forms

Notice To Patients

An Open Payments Database Notice, for informational purposes only, is provided below in the form of a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is at the following link:
https://openpaymentsdata.cms.gov

NOTICE AND ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING

NOTICE TO PATIENTS

I have reviewed the above form and acknowledge that I have
been provided a link to the federal Centers for Medicare and
Medicaid Services (CMS) Open Payments web page.

https://openpaymentsdata.cms.gov

NOTICE AND ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING

NOTICE TO PATIENTS

I have reviewed the above form and acknowledge that I have
been provided a link to the federal Centers for Medicare and
Medicaid Services (CMS) Open Payments web page.

https://openpaymentsdata.cms.gov

Please click the links below to download our printer-ready forms. You can fill them out prior to an appointment and bring with you at the time of your appointment.

Forms in English

Tuberculosis Test Form

Medical Treatment Authorization Form

Tele-Health Visit Consent Form

Financial Policy

Patient Arbitration Agreement

Financial Policy; Medical Lien

Privacy Practices

Workers' Compensation Form

Forms in Spanish

Formulario De Autorización De Tratamiento Médico

Política Finaciera

Acuerdo De Arbitraje Del Paciente

Política Financiera; Gravamen Médico

Prácticas De Privacidad

Make an appointment today with Endure Urgent Care. Call (424) 353-0003

A link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided for informational purposes only. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.