New Patient Packet

Female Questionnaire-New Patient

PACIFIC UROLOGY
100 N. WIGET LANE, SUITE 290, WALNUT CREEK, CA 94598 - (925) 937-7740, FAX (925) 933-9868
2222 EAST STREET, SUITE 250, CONCORD, CA 94520 - (925) 609-7220, FAX (925) 689-3298
5201 NORRIS CANYON RD, SUITE 140, SAN RAMON, CA 94583 - (925) 830-1140, FAX (925) 275-0454

PATIENT INFORMATION

Please Print Clearly & Fill Out Completely

Address

PHYSICIAN INFORMATION

PRIMARY INSURANCE COVERAGE

Complete the following information for the person whose name appears on the Insurance Card:

Does your insurance require a referral to see a Specialist? NO YES (If YES, please give referral slip to Receptionist)

SECONDARY INSURANCE COVERAGE

Complete the following information for the person whose name appears on the insurance card:

Does your insurance require a referral to see a Specialist? NO YES (If YES, please give referral slip to Receptionist)

EMERGENCY CONTACT

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

I authorize my physician and Pacific Urology (PU) to submit insurance claims on my behalf. I authorize my insurance company or its carriers to disclose any information requested by my physicians regarding claims for medical services they provide me. I authorize John Muir Medical Center, San Ramon Valley Medical Center or any other hospital where I may be a patient to release information requested by PU. I authorize PU to release information to physicians referred by PU. I authorize payments of assigned medical benefits to be paid directly to my physician and PU. I am responsible for deductibles, coinsurance, and non-covered items. I agree to pay any co-payments required by my insurance plan at the time of service. I understand that Pacific Urology does not bill tertiary insurances, other than Medicare or MediCal.

PATIENT DEMOGRAPHICS

PRACTICE SELECTION

What factors helped you choose our practice for your medical care? (Check all that apply)

May we keep you informed of PU news & events via confidential Email? Yes No Email:

PATIENT INFORMATION AUTHORIZATION – HIPAA PRIVACY

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of Protected Health Information (PHI). Completion of this form tells us your preferences with regard to telephone messages and whom you give authorization for our office to speak with on your behalf. Further authorization may be needed under more specific circumstances.

CONTACT PREFERENCE (Check ONE): HOME CELL WORK MAIL

Below…Please check ALL that apply:

* Either with any individual, other than yourself, whom answers the phone or on an answering machine.

OTHER AUTHORIZED INDIVIDUALS

Other individuals I authorize to take messages or receive my Protected Health Information are:

I request the following restrictions to the use or disclosure of my health information:

My signature below authorizes Pacific Urology (PU) to use my Protected Health Information per my instructions above and acknowledges that I have received PU’s Notice of Privacy Practices & I consent to the use and disclosure of my health information for treatment, payment or healthcare operations.

PU Witness Name / Signature

Date

FINANCIAL POLICIES

CO-PAYMENT, DEDUCTIBLE & CO-INSURANCE COLLECTION POLICY

We are required by law, and your health plan, to collect co-payments at the time of service. Co-payments are required each time you are seen by the physician or nurse practitioner. This co-payment is for the limited office visit charge that covers the medical management that the physician provides in overseeing your treatment. This policy is established by your health plan and is explained in your benefits handbook and is usually printed on your insurance card.

It is our policy to collect coinsurance and deductibles at the time of service. Prior to any scheduled hospital procedure, any coinsurance and deductible will be collected at the time of the pre-operative visit. If you have any questions or concerns about your insurance coverage, please call your insurance carrier directly.

It is the patient or guardian’s responsibility to determine if the doctor you are seeing is a contracted provider with your insurance. If required insurance cards, co-pays and/or authorizations are not provided at the time of your service, your appointment may be rescheduled.

INSURANCE REIMBURSEMENT & BILLING POLICIES

BILLING STATEMENT: We are happy to bill your insurance as a courtesy to you. Each month you will receive a statement from us describing your current balance and any charges incurred during the statement month. You can submit this bill yourself, along with the appropriate forms, to your insurance carrier. Or, as many of our patients prefer, we will bill your primary and secondary insurance carrier for you. Pacific Urology does not bill tertiary insurance coverage other than Medicare or MediCal. For us to do so, you must sign the “Release of Information & Assignment of Benefits” statement on the first page of this packet. We will bill your insurance a maximum of three (3) times, then the responsibility for handling issues with insurance reimbursement rests with you. You are ultimately responsible for payment of your bill.

When you receive our monthly statement, payment is expected within thirty (30) days. Payments are considered delinquent after sixty (60) days. If Pacific Urology or its physicians are not contracted with your insurance carrier, you are considered a “self-pay” patient and payment is due in full at the time of service.

ATTORNEY FEES AND COLLECTION COSTS:

If any legal action is necessary to enforce or interpret the terms of these billing policies, the prevailing party shall be entitled to reasonable attorneys’ fees, costs and necessary disbursements in addition to any other relief to which that party may be entitled. You agree by your signature below to pay all collection costs, including attorneys’ fees on all delinquent payments.

SUSPENSION OF CARE (EXCEPT EMERGENCY CARE):

If no payment is received after ninety (90) days, we may be forced to suspend all but emergency care until a payment is received. Please discuss all billing issues directly with our billing department.

ADMINISTRATIVE FEES

Due to the high volume of requests we receive, we charge administrative fees for copying of all or part of a medical record, completion of disability forms, printouts of your billing statements, and other such administrative requests. The current fee schedule (which is subject to change) is:

My signature below indicates that I have read, understood and agreed to the Financial Policies of Pacific Urology

PAGES 4-8 ADDITIONAL PATIENT HISTORY

Reason for your visit today? Be precise.

Physician that referred you for care at Pacific Urology:

PAST MEDICAL HISTORY

Do you have or have you had any of the following conditions? YES / NO / Type / Year Diagnosed

PAST SURGICAL HISTORY

Do you have any artificial joints and/or heart valves? Yes No If yes, give which & date:

Have you ever had a blood transfusion? Yes No If yes, when?

GYNECOLOGICAL HISTORY

FAMILY HISTORY

Are you of Ashkenazi Jewish descent? YES NO

Please list any diseases that run in your family, such as cancer, kidney stones, diabetes, etc.

REVIEW OF SYSTEMS

Have you experienced any of these problems during the past month?

URINARY SYMPTOMS

Check appropriate box:

URINARY TRACT INFECTIONS

Check: Gonorrhea Chlamydia Herpes Genital Warts PID Other

INCONTINENCE

KIDNEY STONES

HEMATURIA

SOCIAL HISTORY

CURRENT MEDICATION LIST

ALLERGIES

No Known Allergies Penicillin Codeine Sulfa Cipro Macrobid

CONSENT TO ACCESS MEDICATION HISTORY

In order to provide you with the best possible care, your prescriptions will be written electronically whenever possible. Electronic prescribing is now a common practice due to healthcare initiatives requiring the use of electronic medical records. With your permission, e-prescribing will provide us access your medication history electronically, enabling us to see critically important information on your current and past prescriptions, better assess potential medication issues, and improve safety and quality of care.

By signing below I give my consent to Pacific Urology to access my medication history electronically and to the best of my knowledge, I verify that the above medical information is complete and correct. I understand that it is my responsibility to inform my physician if I ever have a change in my health.

PREFERRED OUTSIDE PHARMACY

Name & Address (Location) of Preferred OUTSIDE Pharmacy:

Is this is a MAIL ORDER PHARMACY? Yes No

Please list a local pharmacy for urgent prescriptions if primary is a mail order.

Name & Address of LOCAL pharmacy: