Potomac Urology Center Patient Registration Form

POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201 Woodbridge, VA 22191 Alexandria, VA 22304 Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
Patient Registration
Name:
Last First Street Address Apt No. MI City State Zip Code
SSN: _____________________Sex: M / F/ Transgender
Home Address: Date of Birth: ____________________ Home Phone: ____________________ Cell Phone: Employer/School: Full-time / Part-time: _______________________________ Email Address: ___________________ Employer/School Address:
Street Address City State Zip Code
Work Number: ________________________ Marital Status: Whom may we thank for referring you today?
Pharmacy Name & Location Pharmacy Phone Primary Care Physician PCP Phone
Emergency Contact
Name: Relationship:
Home Phone: ______________ Mobile Phone: ____________ Work Phone:
Insurance Information ______________________________

Primary Insurance
_________________________________
Secondary Insurance
______________________________
ID Number
_________________________________
ID Number
______________________________
Group Number
_________________________________
Group Number
______________________________
Subscribers Name/Relation
_________________________________
Subscribers Name/Relation
______________________________
Subscribers Social Security Number
_________________________________
Subscribers Social Security Number
______________________________
Subscribers Date of Birth
_________________________________
Subscribers Date of Birth
______________________________
Subscribers Employer
_________________________________
Subscribers Employer
______________________________
_________________________________
Subscribers Address if different than yours Subscribers Address if different than yours I, __________________________________ hereby assign, authorize and request the payment from my insurance carrier be paid directly to Potomac Urology Center, PC. I certify that the information reported is correct, current, valid and complete. I hereby authorize the release of any information for this or any other related claim to my insurance carrier. I also realize that insurance coverage does not guarantee payment for services performed and all charges are my responsibility, with payment in full due within 90 days from the date of service. I will contact my insurance carrier in 2 months, if my claims are still unpaid. I also agree that if there are any balances due or my claim is disputed or denied by my insurance, I will pay in full immediately upon notification from them. I understand that the prices are subject to change. In the event that my account is placed in the hands of a collection agency and/or an attorney, I agree to pay all costs related to the collection, which could be up to 33 1/3% additional to the balance due. I understand that I will be charged $50.00 for all returned checks.
Patient/Parent Signature
Printed Name
DOB
Date

Name: _______________________________________
Last
RACE: CHECK ONE NATIVE HAWAIIAN OR OTHER PACIFIC BLACK OR AFRICAN AMERICAN WHITE HISPANIC OTHER RACE OTHER PACIFIC ISLANDER UNREPORTED/REFUSED TO REPORT LANGUAGE: CHECK ONE ENGLISH SPANISH RUSSIAN INDIAN (INCLUDES HINDI & TAMIL) OTHER
Date of Birth:
MI
ETHNICITY: CHECK ONE HISPANIC OR LATINO NOT HISPANIC OR LATINO REFUSED TO REPORT
First
Health Questionnaire
Reason for Todays Visit:
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Current Medical Conditions:
Past Surgical History: __________________________________________________________________________________________ __________________________________________________________________________________________ _ Are you currently taking medications? Yes No Are you taking Aspirin, Coumadin, Blood Thinners? Yes No Please list medications: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Do you have any allergies to medications? __________________________________________________________________________________________
I hereby consent to treatment by Potomac Urology Center, PC. I hereby authorize Potomac Urology Center, PC to obtain my prescription history and any additional information they may request in regards to my Medication History Signature of Patient (legally responsible party) Date

PAST MEDICAL, FAMILY AND SOCIAL HISTORY

Are you or a blood relative having problems (now or in the past) with any of the following? No Yes If yes, please check all boxes that apply.
YOU FAMILY MEMBER
Anemia Arthritis Asthma Cancer Type of Cancer: Depression Diabetes GERD/Acid Reflux Gout (high uric acid) Heart Disease High Blood Pressure High Cholesterol Kidney Stones Liver Disease Mitral Valve Prolapse Osteoporosis Rheumatic Fever Thyroid Problems Toxic Exposure Tuberculosis Other/Explain: Have you had surgery on any of the following? If yes, please check all boxes that apply.
INCLUDE SURGERY DATE YES NO
Appendix Back Bladder Breast Colon Gallbladder Heart Bypass Heart Valve Hernia Incontinence Kidney Lung Thyroid Urethra Total Joint Replacement
Right: Left: Hip Hip

Knee Knee

Shoulder Shoulder
Printed Name
DOB
Date

SURGERIES CONTINUED: ***WOMEN
ONLY
YES
NO
Hysterectomy Pelvic Laparoscopy Could you be pregnant? Number of Pregnancies:

***MEN
Vaginal
Cesarean
ONLY

Prostate Testicle Vasectomy Have you ever had MRSA? Positive Mantoux/PPD?
BOTH MEN & WOMEN

Do you or did you smoke? Yes No If yes, how many packs per day? _____ How many years? ______When did you quit? _______ Do you drink alcohol? Yes No If yes, how much? _______________ Are you on a special diet? Yes No If yes, explain? __________________ Are you Employed? Yes No Retired Occupation? _____________ Do you have children? Yes No Year(s) of Birth? __________ Do you have any problems NOW related to the following systems? Please circle Yes or No.
Constitutional Symptoms Fever Yes Chills Yes Headache Yes Weight Gain/Loss Yes Other: ________________ Endocrine Excessive thirst Yes Too hot/Cold Yes Tired/Sluggish Yes Other: _______________ Integumentary Skin Rash Yes Boils Yes Persistent rash Yes Other: ________________ Gastrointestinal Abdominal Pain Yes Nausea/Vomiting Yes Indigestion Yes Heartburn Yes Constipation Yes IBS Yes Diarrhea Yes Rectal Bleed Yes Other: ________________ No No No No Cardiovascular Chest Pain Yes No Varicose veins Yes No High/Low blood pressure Other: ________________ Ear/Nose/Throat/Mouth Ear Infection Yes No Sore throat Yes No Sinus problems Yes No Other: ________________ Sexual History Sexually active? Yes No Pain with intercourse? Yes No Leaking urine with intercourse? Yes No Other: ________________ Hematologic/Lymphatic Swollen glands Yes No Blood clotting Problem? Yes No Pulmonary Embolism Yes No Anemia Yes No HIV/AIDS Yes No Other: ________________ Respiratory Wheezing Yes No Frequent cough Yes No Shortness of breathe Yes No Other: ________________ Gynecologic Heavy periods Yes No Irregular periods Yes No Menopause Yes No If yes, when? ____________ Hormone therapy Yes No Other: ________________ Neurological Tremors Yes No Dizzy Spells Yes No Numbness Yes No Headaches Yes No Other: ________________ Eyes Blurred Vision Yes No Boils Yes No Persistent rash Yes No Other: _______________
No No No
No No No
No No No No No No No No
Printed Name
DOB
Date

Billing Policies
ASSIGNMENT OF BENEFITS: I hereby assign to you Potomac Urology Center, PC, all medical benefits to what I am entitled, including Medicare or any other insurance plan. I hereby authorize said assignee, Potomac Urology Center, PC to release all information to secure payment, including appeals on my behalf to the Insurance Commissioner. I also authorize my insurance company to release any/all information to Potomac Urology Center, PC that may be necessary to secure payment. I also understand that I am financially responsible for all charges my insurance company states are patient responsibility, including any deductibles and copayments and that payments are due at the time services are rendered. If Potomac Urology Center, PC does not participate with my insurance company, I understand that I am responsible for all charges not paid by my insurance. I also understand that if I am signing on behalf of my minor dependent, that I am responsible for all charges rendered patient responsibility. I understand that in the event my account becomes past due (over 90 days) and all attempts to arrange payment have failed, my account will be turned over to a collection agency and/or attorney. I also understand that I will be responsible for all collection agency fees (33 1/3%) of total past due amount and all other costs expended to the collection said amount. NO SHOW FEE: It is our policy to require appointment cancellations no later than 48 hours in advance in order to avoid a no show charge. Effective January 2, 2011 failure to notify Potomac Urology Center, PC within this time limit or failure to show up for scheduled appointment will result in a $50 Office Visit fee, $200 CMG Testing fee, $100 Cystoscopy fee, $500 Hospital Surgery fee, $100 Surgical Procedures in Office fee & $250 Vasectomy fee to your account. This charge cannot be billed to any insurance company, IT IS YOUR RESPONSIBILITY. You will receive a bill for this and payment is expected prior to your next appointment. HMO PATIENTS: Potomac Urology Center, PC is a specialty medical practice. IT IS YOUR RESPONSIBILITY TO OBTAIN REQUIRED REFERRALS FROM YOUR PRIMARY CARE PHYSICIAN PRIOR TO EACH VISIT. For return patients, if you are uncertain whether or not you have a valid referral on file, please call the office 48 hours prior to your visit to clarify the issue. Appointments will be rescheduled if required referrals are not presented prior to or on the scheduled appointment day. PRIVACY NOTICE: My signature below confirms that I was given the opportunity to read, understand and ask questions about Potomac Urology Center, PC Notice of Privacy Practices exhibited in the waiting room (copy given upon request). I hereby authorize Potomac Urology Center, PC to release any information pertaining to my health care, test results, billing and/or accounting information to the following person(s) or agencies. I understand that I have a right to inspect and receive a copy of the disclosed material at a cost of $10 administration fee, $0.50 per page for the first 50 pages and $0.25 per page after 50 pages. These charges are in accordance with the VA CODE A01-4V13. I also understand that Potomac Urology Center, PC charges $25 to complete any additional forms. Myself My Significant Other Leave information on my voice mail Others (specify): _____________________________________________ _____________________________________________ _____________________________________________ I certify that I understand and agree with the above policies. I also certify that the information I have given is correct to the best of my knowledge.
Printed Name
DOB
Date

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POTOMAC UROLOGY CENTER

SSN: _____________________Sex: M / F/ Transgender

Home Phone: __ Mobile Phone: Work Phone:

Insurance Information ______________________________