Patient Forms

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
Appointment 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

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.

Patient Demographic Information
Section 3: Patient Permissions

The Permissions 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.

I hereby grant permission on the use and/disclosure of my information to the following people. I understand that they may call on my behalf to update my billing and insurance files, coordinate care by scheduling appointments, and talk to staff and MD regarding my care. I also understand that the staff will ask them to acknowledge my date of birth or last 4 digits of my social security number as my patient identifier.

Section 4: MIPS and MACRA

Federal Government Mandated Changes – Effective January 1, 2017

What is MACRA?

President Obama signed into law the Medicare Access and CHIP Reauthorization Act (MACRA) on April 16, 2015. MACRA combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) incentive program into one single program called the Merit-based Incentive Payment System, or “MIPS”. MIPS will determine Medicare payment adjustments and is an acronym for the Merit-Based Incentive Payment System. Performance for MIPS will start on January 1, 2017 and will annually measure eligible providers in four performance categories to derive a “MIPS score” (0 to 100). The four performance categories are weighted as follows: 50% for quality (PQRS/VBM),  25% for Meaningful Use, 15% for clinical practice improvement and 10% for resource use. 

Why do I need to provide this information if I am not a Medicare Recipient?

Most often when CMS takes the lead on creating new programs to try and decrease health care cost, Private Pay Insurers follow suit.  By creating systems to capture the data for all patients, at the same time, it makes it easier for the practice and enables UTPA to meet Quality Measures established by your Insurance provider as they duplicate these programs for their recipients.   

We know that you may see these questions again and again if you see multiple providers and we thank you in advance for your cooperation.     - The Urology Team MD’s

Advanced Care Planning *
Influenza *
Pneumonia *
Patient History Form
Physician & Pharmacy Information
Medications List
Please list all current medications & supplements or attach separate list. (Please print) Please use this format: Medication Name | Dosage (i.e. 25mg) | # of tabs | How Often? (i.e. twice a day)
Medication 1
Allergy Record
Please list all current allergies to medications and substance reactions (latex, food, etc.) Please use this format: Medication or Substance Name | Reaction
Review of Systems
Please indicate any of the following symptoms or conditions that you are CURRENTLY having.
Past Medical History
Please indicate whether you have had any of the following conditions IN THE PAST.
Past Surgical History
Please indicate whether and when you have had any of the following surgeries. Use last box in each category to indicate any surgeries not listed.
Cardiovascular
Gastrointestinal
Colorectal Screening *
Genital / Urinary
OB/GYN
Head / Ears / Eyes / Neck / Throat
Musculoskeletal
Respiratory
Skin
Family History
Please indicate whether anyone in your family has had the following conditions including mother, father,sister, brother, aunt, uncle, grandfather, grandmother.

By submitting this form, you acknowledge that you personally supplied the included information and attest that it is true and complete to the best of your knowledge.  The information submitted is strictly confidential and will not be released to anyone without your written consent, unless by court order.