Patient’s Name  ___________________________________________________
                                      Last                              First                     Middle Initial

Social Security Number ____________________________________________

Date of Birth _____/_____/_____  Age _____ Sex ____ Marital Status:  S  M  D  W

Home Address (Street) _______________________________________________

                         (City) _____________________(State) _______(Zip)__________

Home Phone (_____) _______________    Work Phone (_____) ______________

Cell Phone  (_____) _______________    

Referring Doctor __________________ Address __________________________

Family Doctor ____________________ Address __________________________

Allergies To Medication ______________________________________________

Patient’s Employer __________________________________________________

Spouse (or) Parent’s Name ____________________________________________

Spouse (or) Parent’s Employer _________________________________________

Spouse (or) Parent’s Work Phone (_____)_______________

Primary Insurance ____________________ Subscriber ID ___________________

Subscriber’s Name (On Card) _____________ Subscriber’s DOB ______________

Subscriber’s Social Security Number (If different than Subscriber ID) ___________

Subscriber’s Employer ________________________________________________

SEQ # _____ Group # ______ Co Pay $ ________ County # (Medicaid Only) _____

   Network # _______________   Benefit Plan: _______________

Alliance _____ Alliance Select ______ Unity Choice _____ Effective Date: _______

Secondary Insurance ____________________ Subscriber ID __________________

Subscriber’s Name (On Card) _____________ Subscriber’s DOB ______________

Subscriber’s Employer ________________________________________________

SEQ # _____ Group # ______ Co Pay $ ________ County # (Medicaid Only) _____

Alliance _____ Alliance Select ______ Unity Choice _____ Effective Date: _______

Does the Patient have an answering machine for incoming messages?    Y    N

May we leave confidential messages on your answering machine?          Y    N

Please list below the name and date of birth of anyone you give us permission to give out confidential information to:

Name ______________________________ Date of Birth ____________________

Name ______________________________ Date of Birth ____________________

 CONSENT FOR TREATMENT AND RELEASE FROM RESPONSIBILITY.

I, the undersigned, being informed that I am or may be suffering from a condition which requires medical services, diagnosis, and or surgical treatment, do voluntarily consent to and authorize physician services, including laboratory and X-ray procedures, and medical and surgical treatment as my physician, including his assistants may deem necessary.  I acknowledge that no guarantees have been made to me or anyone else on my behalf, as to the results of such services and procedures.

 FINANCIAL AGREEMENT.

I, the undersigned, agree to pay for services rendered.  The account is to be paid in full within 90 days of the date of service.  Any amount not covered by my insurance carrier will become my responsibility.  I agree to notify my insurance carrier prior to any admission or outpatient procedure.  It will be my responsibility to obtain a second opinion, prior approval or pre-admission certification, as deemed necessary by my insurance carrier.  I understand that if these requirements are not met, the insurance payment will be reduced, and I will be responsible for payment of this amount.

 RELEASE OF INFORMATION.

Urologic Associates of Iowa City, P.C., may disclose all or part of the patient’s medical record, pertinent information or an opinion concerning the patient’s medical condition and treatment as requested or required by the patient’s insurance carrier, health maintenance organization, worker’s compensation, Medicare, self-insured organizations, utilization review, or managed care organizations.  Urologic Associates has my permission to release information to an insurance company as the patient applies for new insurance.

ASSIGNMENT OF BENEFITS.

I request that payment of authorized insurance or Medicare benefits be made on my behalf to Urologic Associates of Iowa City, P.C., for services rendered.

Signature of Patient _____________________________ Date ________________

PLEASE SHOW INSURANCE CARD TO RECEPTIONIST