What to Bring to Your Appointment Patient Forms Insurance and Payment Information Questionnaires Privacy Practices

What to Bring to Your Appointment

• Your insurance card
• Physician referral forms, if required by insurance
• List of prescriptions and/or over-the-counter medication, including dose and frequency (see master medications sheet below)
• Information about your medical and surgical history
• Recent x-rays or relevant records
• Completed patient forms

Patient Forms

You can view and/or print the necessary patient forms for your appointment by following these easy instructions. In order to view and/or print the forms, you must have the Adobe Acrobat Reader®, which you probably already have on your computer. If not, you can easily and quickly download a free version of Adobe Acrobat Reader by going to their website Download Reader.

When viewing the forms in Adobe Acrobat Reader, the text might appear somewhat fuzzy; this is normal (the forms will print out clearly). To print, just click on the printer icon in the Adobe Reader toolbar above the document.

Once you have the Adobe Acrobat Reader installed, click on these links to view and print the following forms:

• Patient information form
• Patient health history form
• Patient authorization form, for release of information
• Patient consent form, for Notice of Privacy Practices
• Financial Policy
• American Urological Association Symptom Index
  for Benign Prostatic Hyperplasia
  (International Prostate Symptom Score)
• The 5-Item Version
  of the International Index
  of Erectile Dysfunction (IIEF-5)

Insurance and Payment Information

Urology Consultants is a provider for Medicare and most major insurance plans, and provides insurance billing. You are responsible for charges that are not covered by your insurance, at the time of your appointment.

Your insurance company may require a co-payment at the time of your appointment. When necessary, our staff will work with patients to set up a payment plan.

If you have questions regarding billing or which insurance plans we accept, please call us at the phone number below. Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.

Questionnaires

You can view and/or print the questionnaires by following these easy instructions. In order to view and/or print the questionnaires, you must have the Adobe Acrobat Reader®, which you probably already have on your computer. If not, you can easily and quickly download a free version of Adobe Acrobat Reader by going to their website Download Reader.

When viewing a questionnaire in Adobe Acrobat Reader, the text might appear somewhat fuzzy; this is normal (the questionnaire will print out clearly). To print, just click on the printer icon in the Adobe Reader toolbar above the document.

Once you have the Adobe Acrobat Reader installed, click on these links to view and print the following questionnaires:

• view/print Impotence Questionnaire
• view/print Prostate Questionnaire

Privacy Practices

Notice of Privacy Practices for Urology Consultants
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.