NOTIFY THE RECEPTIONIST IMMEDIATELY IF YOU FEEL YOU ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section 1, General Information. Enter your last name, first name, middle initial, date of birth, and social security number. Provide your complete address and contact numbers.
3. In Section 2, Insurance Information, input the primary cardholder's details. If the cardholder is the same as you, check the designated box to skip to Section 3.
4. For Section 3, specify the reason for your visit and any applicable co-pay amount. Answer questions regarding work-related visits or accidents as necessary.
5. If applicable, complete Section 4 for Guarantor Information if you are a minor or dependent. Fill in all required fields accurately.
6. Continue with Sections 5 through 7 as needed, providing information on how you heard about Lansing Urgent Care and any secondary insurance details.

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