Medical History Form

 
1 Start 2 Please click here to complete these three sections 3 PAGE 1 OF 4 4 PAGE 2 OF 4 5 PAGE 3 OF 4 6 Complete

The completion of your paperwork is very important to the physician for your care. 

The information provided is also supportive documentation should we be denied a claim filed to your insurance company on your behalf. 

(There is also a downloadable PDF that you can print and fax to us here.) We thank you for your time and attention to this task.

Patient Information
Section 1: Miscellaneous forms
The heading for each of the following sections is a live link that will direct you to more information. After reviewing each section, either "Accept" or "Decline". You must choose to either "Accept" or "Decline" before you are able to move on to the next section.

HIPAA

Read HIPAA
I understand that The Urology Team has posted the HIPAA throughout the office. I acknowledge that I can request a copy of the Notice of Privacy Policy at any time.

General Clinic Policies

Read General Clinic Policies
I have read and understand the General Clinic Policy and agree to its terms and acknowledge that the Practice may amend from time to time. I acknowledge that I can request a copy at any time.

Financial Policies

Read Financial Policies
I have read and understand the Financial Policy and agree to its terms and acknowledge that the Practice may amend from time to time. I acknowledge that I can request a copy at any time.

Reconciliation Policy

Read Reconciliation Policy
I have read and understand the Reconciliation Policy and agree to its terms and acknowledge that the Practice may amend from time to time. I acknowledge that I can request a copy at any time.

Patient Rights and Responsibilities

Read Patient Rights and Responsibilities
I have read and understand the Patient Rights and Responsibilities and agree to its terms and acknowledge that the Practice may amend from time to time. I acknowledge that I can request a copy at any time.

Section 2: Demographics, Permissions/Passwords and Medical History
Section 2 is broken into three sections: Demographics, Permissions/Passwords and Medication /Medical History

The Demographic data collection section was launched by the Federal Government in 2008 geared to establishing a system of Electronic Health Records that should improve health care quality, efficiency, patient safety, reduction of health disparities, engagement of patient and families, care coordination. This section is not used as determinants of eligibility for participation in any Federal program. For more information about this federally mandated program for physicians, please visit www.healthit.hhs.gov. The Permissions/Passwords section allows another person(s) to access your medical information with your permission. You are asked to list one or two individuals that you have given permission to access your information, make or change appointments, etc. You will be asked to choose a password that these individuals would need to use in order to access your information. The last section, Medication/Medical History, provides information for the physician to prepare for your visit.