Authorization of Treatment / Assignment of Benefits Form ...



LVPG Urology - Muhlenberg

2597 Schoenersville Rd, Suite 201

Bethlehem, PA 18017

(P) 484-884-3600 (F) 484-884-3610

We would like to thank you for choosing

LVPG Urology - Muhlenberg.

Please complete all attached forms before your first appointment. In order to provide you with the most complete and comprehensive evaluation on the day of your visit, it is very important that we have your complete medical information regarding your past and present health.

If you have had any of the following tests we will need to have the images put on a disc before your appointment. All ultrasounds, X-rays, CT scans, MRIs or a previous NOT performed at:

Lehigh Valley Hospital

Lehigh Valley Diagnostic Imaging

Lehigh Magnetic Imaging Center

**YOU MAY BE ASKED TO PROVIDE A URINE SAMPLE**

Please bring your insurance card(s), photo identification AND prescription card with you on the day of your visit. If your insurance requires that you have a referral, please request this from your primary care physician as soon as possible and have it faxed to our office prior to your appointment.

If you need to cancel or reschedule for any reason, please call at least 24 hours in advance. Do not hesitate to call our office if you have any questions or concerns. We look forward to meeting you in the near future.

If this visit is for a vasectomy consult please call the number on the back of your card to see if this consult and the procedure itself is a covered service. If this procedure is not a covered service the patient will be responsible for the cost of the consult/procedure.

Thank you from all of us here at LVPG Urology!

LVPG Urology - Muhlenberg

2597 Schoenersville Rd, Suite 201

Bethlehem, PA 18017

(P) 484-884-3600 (F) 484-884-3610

Patient Information

Name: ____________________________________________________________ Sex: M / F Date of Birth: __________________

Nickname: __________________________ Social Security: ____________________________

Street Address: ___________________________________________________________________________________________________

Street, PO Box City State Zip

Contact Phone Numbers (home, work, cell): Employer:

Primary: ________________________________ (H/W/C) Company Name: _______________________________________

Secondary: ______________________________ (H/W/C) Address: ______________________________________________

Alternate: _______________________________ (H/W/C) ______________________________________________

E-Mail Address: __________________________________________ Status(circle one): Full-time / Part-time / Retired / Not employed

Additional Information

Preferred Spoken Language: ________________________ Preferred Written Language: _____________________

Race: ____________________/ Decline Ethnicity: Hispanic / Non-Hispanic / Refused Marital Status: M / S / D / W

Religion: _____________________ / Decline Veteran: Y / N Branch: ____________________

Pharmacy Name and Address: ______________________________________________________________________________

Referring Physician Name: ____________________________________/ Self Referring Physician Phone #: ______________________

Primary Care Physician Name: _________________________________/ None Primary Physician Phone #: _______________________

Emergency Contact

Emergency Contact: ___________________________________ Relationship to you: ________________Contact #: __________________

Insurance Information

Primary Insurance Company: ____________________________________________ Referrals Required: Y / N

Primary Insured Name: _____________________________________ Insured Relationship to Patient: _______________

(Are you the policy holder or is your spouse/parent?) (Parent, Legal Guardian, Spouse)

Insured Date of Birth: _______________ Insured Social Security Number: _______________________

Secondary Insurance Company: __________________________________________ Referrals Required: Y / N

Primary Insured Name: _____________________________________ Insured Relationship to Patient: _______________

(Are you the policy holder or is your spouse/parent?) (Parent, Legal Guardian, Spouse)

Insured Date of Birth: _______________ Insured Social Security Number: _______________________

Patient/Guardian Signature: ____________________________________________ Date: _______________

|LVPG Medical Information Communication Preferences |

As our patient, we may need to communicate with you when you are not in the practice. To maintain your privacy, please indicate your preferred method for us to communicate confidential medical information, such as test or lab results, to you and/or others involved in your care. Please note that “appointment reminder telephone calls” may be left at the contact number(s) you list below.

PLEASE INDICATE YOUR COMMUNICATION PREFERENCES BELOW:

( I give permission to leave medical information pertaining to me, my dependent or child, at the numbers listed below:

|Method |Yes |No |Area Code, Phone #, Ext, E-mail |

|Home telephone | | | |

|Answering Machine | | | |

|Work Phone | | | |

|Cell Phone | | | |

|Secure E-mail (Patient Portal secure email registration | | | |

|only) | | | |

|Pager | | | |

Without specific permission, we will not release any medical information to anyone other than you. In some cases you may wish for another person to have access to your medical information. Please identify those individuals and their relationship to you (i.e. spouse, parent, son, daughter, partner etc.):

( Do not release medical information to anyone other than myself.

( I give permission to release medical information pertaining to me to the individuals listed below.

| |Relationship (i.e. spouse, parent, son, daughter, etc.) | |

|Name | |Area Code, Phone # - Extension |

| | | |

| | | |

| | | |

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|Comments |

I assume responsibility to inform the practice of changes in my phone number(s) or my preferences or to revoke this specific medical information authorization at any time.

___________________________________________________ ______________________

Signature of Patient or Patient’s Legal Representative Date

___________________________________________________(Please Print Signer’s Name)

Medical History Questionnaire

Name: ________________________________ MRN: ________________________

Do you have an advance directive? □ Yes □ No

Are you a victim of violence or abuse? □ Yes □ No

Had a flu shot this year? □ Yes □ No

Had a pneumonia shot? □ Yes □ No

|Describe briefly in your own words, the major medical problem or need that brings you to see our physicians, and when the problem began? |

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Medical History

Please list any medical problems you have; add any details that might be helpful.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Surgical History

Please list any surgeries you have had.

|Surgery |Reason |Hospital / State |Year |

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Medications/Dosages

Please list medications and supplements you take.

Instead of writing your medications you may bring a list of them with you to your appointment.

|Medication |Dose |Medication |Dose |Medication |Dose |

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Allergies

Please list any medications, foods, or other substance to which you have had an allergic reaction to.

|Medication / Other |Reaction |

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Social History

1. Are you sexually active? □ Yes □ No □ Not currently Partner: □ Male □ Female

2. Current method/form of birth control? __________________________ □Not Applicable

3. How many children do you have? ____________

4. Are you currently employed outside the home? □ Yes □ No

5. Are you retired? □ Yes □ No

6. Have you ever smoked? □ Yes □ No

If yes, number per day ______

How many years did you smoke? ______

Have you quit? □ Yes □ No

7. Do you drink alcoholic beverages? □ Yes □ No

Amount per day/week? _____

8. If you previously drank heavily, how much, when did you quit? ______________

9. Do you use illegal substances or drugs? □ Yes □ No

If yes, which one(s)? __________________________

Family History

List any relatives who have or previously had cancer, indicate the location of cancer or tumor, and how the individual was related to you.

|Relative |Location of cancer / tumor |Age of diagnosis |

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MALE ONLY

TESTOSTERONE SCORE

1.  Do you have a decrease in libido (sex drive)?

2.  Do you have a lack of energy?

3.  Do you have a decrease in strength and/or endurance?

4.  Have you lost height?

5.  Have you noticed a decreased enjoyment in life?

6.  Are you sad and/or grumpy?

7.  Are your erections less strong?

8.  Have you noted a recent deterioration in your ability to play sports?

9.  Are you falling asleep soon after dinner?

10.  Has there been a recent deterioration in your work performance?

WOMEN ONLY

1. How many times have you been pregnant? _______

2. How many times have you delivered a baby? _______

3. How old were you when you delivered your first baby? ______

4. When was your last PAP smear? _______

5. When was your first menstrual period? _______

6. When was your last menstrual period? _______

7. Had you previously had a breast biopsy? _______

If so, when and where? ______________________________________________

8. Have you gone through menopause? Y / N

9. Do you do self-breast examinations? Y / N

How frequently? _____________________________

10. Have you used hormone replacement therapy? Y / N

If yes, what type _____________________________________________________

How long? __________________________________________________________

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