Date Referring Doctor Referring Doctor Phone # ( ) PATIENT INFORMATION First Name Last Name Nickname Address M.I. Apt # City State Home Phone ( ) Work Phone (include ext) ( ) Social Security # Cell Phone ( ) Sex  Male Zip Email Address (to be used if permission is given) Date of Birth Age  Female Employer Occupation Spouse’s Name Marital Status  Single  Married  Widowed  Divorced EMERGENCY CONTACT INFORMATION Relationship to Patient Phone #1 ( ) Name Phone #2 ( ) RESPONSIBLE PARTY INFORMATION (if different from Patient Information) First Name Last Name Address Apt # Home Phone ( ) Work Phone (include ext) ( ) City Cell Phone ( ) M.I. State Relationship to Patient INSURANCE INFORMATION PRIVATE OR GROUP INSURANCE Insurance Name: Insurance Phone #: Claims Address: MEDICARE Claim #: Hospital Effective Date: Medical Effective Date: Subscriber Name: Subscriber Date of Birth: Subscriber Social Security: Employer: SECONDARY Insurance Name: Insurance Phone #: Claims Address: ID#: Group#: Subscriber Name: Subscriber Date of Birth: Subscriber Social Security: Employer: MEDICAID Medicaid ID #: Eligibility Date: ID#: Group#: Are you a resident of a Nursing Home Facility? YES NO If yes, what is the Facility Name: ___________________________________________________________________ Address: ___________________________________________________________________ Phone #: ____________________________________________________________________ **Patient must be accompanied by an informed caregiver.** ______________________________________________________ Patient Signature ________________________________ Date Signed Zip Name: _______________________________________ Date of Birth: _____/_____/_____ Today’s Date: _____/_____/_____ Age: ________ Weight: ________ Height: _________ Sex:  Male  Female Marital Status: S M W D Referring Doctor: _______________________________________ Primary Doctor: _________________________________ Please list any additional doctors who you want to have copies of your information (please include phone numbers): _________ _______________________________________________________________________________________________________ What is the main reason for your visit today? __________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ _ Personal History YES Anxiety  Asthma  Blood Clotting Problems  BPH/Enlarged prostate  Cancer  Type _____________________________                     Depression Diabetes Erectile Dysfunction (ED) Gastrointestinal Disease Glaucoma Heart Disease Heart Valve Disease High Blood Pressure AIDS/HIV+ Liver Disease Lung Disease Prostatitis Renal/Kidney Disease Stroke Sexual Transmitted Disease (STD) Tuberculosis (TB) Thyroid Disease Urinary Problems Urinary Tract Infections (Recurrent) Weight Loss NO                          Family History YES Anxiety  Asthma  Bleeding Problems  Cancer  Type _____________________________ Depression Diabetes Enlarged prostate Gastrointestinal Disease Heart Disease Heart Valve Disease High Blood Pressure Liver Disease Lung Disease Renal/Kidney Disease Tuberculosis (TB) Thyroid Disease Urinary Problems NO                               Other (List)___________________________________________ Have you ever had a problem with Anesthesia? Y N Other (List)_________________________________________ Medication Allergies _______________________________________________________________________________________ ________________________________________________________________________________________________________ Other Allergies (such as latex, any type of contrast, shellfish, etc.) ______________________________________________________ Have you ever smoked? Y N If yes, how long?____________________ Have you quit smoking? Y N If yes, when?________________________ Caffeine intake? Y N How many packs per day?_____________ If yes, what type____________________________ Amount per day ___________________ On average, how many alcoholic beverages do you consume each day? ______________________________________________ How many children do you have ______ # of vaginal deliveries ______ First day of last menstrual cycle _______________ # of C-sections ______ # of pregnancies ______ History is the Key to Diagnosis Name: _______________________________________ Date of Birth: _____/_____/_____ Today’s Date: _____/_____/_____ CONSTITUTIONAL Fever Chills Headache Unexpected weight loss Recent weight gain Blurred vision Double vision Glaucoma Cataracts AIDS HIV+ NEUROLOGICAL Seizures Dizzy spells (recent) Fainting spells Epilepsy Past strokes Numbness in any part of the body GASTROINTESTINAL (GI) Frequent indigestion Change in bowel habits Blood in stool Hepatitis/liver disease Recurrent pain in abdomen Persistent diarrhea/constipation Difficulty swallowing Rectal bleeding Ulcers Lost bowel control CARDIOVASCULAR/RESPIRATORY Pain, discomfort, tightness in chest Shortness of breath Chronic or frequent cough Spitting up blood Thumping, irregular or racing heart Heart attack Hypertension (high blood pressure) High cholesterol Heart disease Ankle swelling Heart murmur Pain in calves/legs when walking wheezing DERMATOLOGY Skin rash Severe itching Jaundice skin (yellowish skin) HEMATOLOGIC/LYMPHATIC Anemia Bruise easily Blood transfusion in past 6 months EAR/NOSE/THROAT/MOUTH Sore throat Sinus problems Difficulty hearing Wear dentures Severe nosebleeds YES NO GENITOURINARY Blood in urine Kidney stones/kidney disease Difficult or painful urination History or urinary infections Sexual problems Frequent urination Urine retention Leakage of urine Getting up at night to urinate # of times 1 2 3 4+ YES NO YES NO MUSCULOSKELETAL Joint pain Back pain Muscle cramps Muscle weakness ENDOCRINE Excessive thirsty Fatigue EXTREMITIES – NEUROLOGIC Low back pain Back pain which goes into your legs Trouble with hands, feet or ankles Numbness in any part of the body Arthritis FEMALE ONLY Unexplained vaginal bleeding Persistent vaginal discharge Lumps in breast Urinary tract infections with pregnancy Pain with intercourse Birth control pills Have you had regular pap smear exams Number of pregnancies Number of miscarriages MALE ONLY Swelling or lumps in testicles YES NO YES NO YES NO YES NO YES NO YES YES NO NO PAST SURGICAL HISTORY Approx. Date YES NO YES NO NO Type of Surgery YES Facility/Physician MEDICATION LOG SHEET Patient’s Name ________________________________________________________________ DOB __________________________ Preferred Pharmacy & Phone #: ______________________________________________ Patient’s Dr._______________ Medication Allergies __________________________________________________________________________________ __________________________________________________________________________________ Other Allergies (such as latex, any type of contrast, shellfish, etc.) ____________________________________________________________ PATIENT USE ONLY Medication(s) and Dosage Date Date Reviewed By (initials) **If additional space is required please use back of this form** Date Date Date Date Date Date Date UROLOGY AUSTIN BRETT W. BAKER, M.D. CARL J. BISCHOFF, M.D. R. GRADY BRUCE, M.D. DAVID C. CUELLAR, M.D. NARESH V. DESIREDDI, M.D. MICHAEL K. FLOYD, M.D. DAVID W. FREIDBERG, M.D., F.A.C.S. JOHN J. HORAN, M.D. JEFFREY N. KOCUREK, M.D. SHAUN A. MALONEY, M.D. MICHAEL L. MCCLELLAND, JR., M.D. ROBERT O. NORTHWAY III, M.D. DAVID L. PHILLIPS, M.D. STEVEN H. PICKETT, M.D., PH.D. MATHEW J. PUTZI, M.D. PETER A. RUFF, M.D. HERB SINGH, M.D. NOAH A. TAYLOR, M.D. JOHN C. WILLIAMSON, M.D. RELEASE OF INFORMATION  __________ I hereby release Urology Austin to furnish medical or other information concerning my present illness or injury to my INITIAL family physician(s), Medicare, or insurance companies.  __________ I further authorize my family physician(s), referring physician(s), and other care providers to furnish any and all information INITIAL concerning my present illness or injury to Urology Austin.  __________ I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF AN ORIGINAL. INITIAL  __________ I further authorize Urology Austin to leave information and appointment reminders at the following: INITIAL  Home _____________________  Work _____________________  Cell _____________________  Email ______________________________________________________________________________________  __________ I give Urology Austin permission to release information regarding my healthcare including, but not limited to, appointment INITIAL information, test results, diagnosis, etc.; whether in written, oral, and/or electronic format to the following individuals (please include contact information):_____________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ _ ____________________________________________________________________________________________________ ASSIGNMENT OF BENEFITS I further request payment of surgical and/or medical benefits, otherwise payable to me, directly to Urology Austin for services provided. I understand that I am financially responsible to Urology Austin for charges not covered by the Assignment of Benefits. ____________________________________________________________ Patient Signature ________________________________ Date Signed ___________________________________________________________ Responsible Party/Parent/Guardian Signature ________________________________ Date Signed I hereby acknowledge that I have been presented with Urology Austin’s Notice of Privacy Practices (HIPPA). _______________________________________________________ Signature _______________________________ Date Signed ______________________________________________________ Name of Patient (please print) _______________________________ Patient’s Date of Birth UROLOGY AUSTIN BRETT W. BAKER, M.D. R. GRADY BRUCE, M.D. DAVID C. CUELLAR, M.D. MICHAEL K. FLOYD, M.D. DAVID W. FREIDBERG, M.D., F.A.C.S. JOHN J. HORAN, M.D. JEFFREY N. KOCUREK, M.D. SHAUN A. MALONEY, M.D. MICHAEL L. MCCLELLAND, JR., M.D. ROBERT O. NORTHWAY III, M.D. DAVID L. PHILLIPS, M.D. STEVEN H. PICKETT, M.D., PH.D. PETER A. RUFF, M.D. HERB SINGH, M.D. H. CLIFF WALKER, PA-C JOHN C. WILLIAMSON, M.D. FINANCIAL POLICY **Please read carefully, initial where indicated and sign below** _________ Initial Insurance co-pays are due AT THE TIME OF SERVICE and before you see the doctor; if you are unable to pay your co-pay you may be asked to reschedule your appointment. Due to the fact that Urology Austin physicians are specialists, higher co-pays may be applied. _________ Initial It is the patient’s responsibility to obtain all referrals from the primary care physician, when applicable. If you do not have a current referral on file, you will be asked to reschedule your appointment. _________ Initial It is the patient’s responsibility to know where your insurance company REQUIRES you to obtain any labs, x-rays, and any other ancillary services. Please let your doctor’s medical assistant or nurse know so that they may schedule things accordingly. _________ Initial CT scans & in office surgeries typically are applied towards your deductible, co-insurance and outof-pocket amounts. All fees will be due prior to the CT or surgical procedures being done, unless pre-arranged prior to visit date. _________ Initial Lab services cannot be billed until the date the test is performed, regardless of the date specimen is obtained. _________ Initial Urology Austin follows governmental guidelines for billing our services. Many insurance companies will process charges for ancillary services (labs, x-rays, to include CT scans; procedures, etc.) and make the patient responsible for balances above the office co-pay. This could be in the form of deductibles, co-insurance or additional co-pays. We participate with many insurance companies to enable our patient’s affordable medical care. Because of this, we are obligated to follow the guidelines that the insurance companies give us on patient balances. If you have specific questions about how your insurance company processed your claim, please call them directly. _________ Initial If we do NOT participate with your insurance company, you will be considered a self-pay patient. The protocol for self-pay patients, as seen below, will apply. As a courtesy, we can submit a claim to the insurance company on your behalf, and your insurance company can reimburse you. FOR SELF-PAY PATIENTS ONLY ________ If you do not have insurance you will be considered a self-pay patient, which means that upon arrival Initial before seeing the doctor you will need to pay $250.00. When you check out we will apply a 20% discount and collect the remaining monies. Please note that if you are unable to pay the remaining balance at check-out the 20% discount will NOT be applied to the balance (we accept MasterCard, Visa, cash, & checks). By signing this financial policy I acknowledge that I have read and understand the above information. The patient MUST initial and sign this financial policy. _______________________________________________ Patient Signature _________________________ Date Signed PATIENT PAY CONSENT FORM Patient Name __________________________________________________ Date of Birth _____________________ Patients Doctor: _______________________________________________ I assign my insurance benefits to the provider listed above. I understand that this form is valid for one year unless I cancel the authorization through written notice to the health care provider. I authorize Urology Austin to maintain my credit/debit card on file for the co-pays & balance of charges not paid by my insurance company, as well as for any other outstanding balances. Cardholder Name __________________________________________________________________________________ Cardholder Billing Address __________________________________________________________________________ City ________________________________________ State ________ Zip Code _____________________________ Card Number __________-__________-__________-__________ Expiration Date _____________ V-Code _______ I agree to notify Urology Austin in advance of my credit/debit cards expiration. I understand that by signing this form I am authorizing Urology Austin to collect monies under the terms listed above and I also understand in order to change or cancel the above information I must do so in writing. I also understand that a total of 3 attempts will be made to process payment and if after the 3rd attempt payment still has not been processed I understand that our normal collection procedures will go into effect. Cardholder Signature _____________________________________________ Date Signed _____________________ Do you want credit/debit card receipts to be mailed to the cardholder’s billing address? □YES □NO, if not please give us the alternate address _______________________________________________ City ___________________ State ______ Zip __________ (This information will be kept confidential and will be kept in a securely locked place in our office.)