Date Referring Doctor Referring Doctor Phone #

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.)