PLEASE PRINT AND FILL OUT COMPLETELY - Urology Group …



PLEASE PRINT AND FILL OUT COMPLETELY

_____________________________________________________ _________________________ _____________________

NAME: LAST FIRST MI PRIMARY CARE PROVIDER REFERRING PROVIDER

_______ M F / / . _______-______-__________ ___________________________________________

AGE SEX DATE OF BIRTH SOCIAL SECURITY NUMBER E- MAIL

__________________________________________________________________________________ __________________

ADDRESS: STREET APT# CITY STATE ZIP HOME PHONE

EMPLOYER:________________________________ OCCUPATION:________________ Email: _________________________

WORK ADDRESS:____________________________________________________WORK PHONE:________________________

MARITAL STATUS: S M W D SPOUSE’S NAME________________________________________________________

SPOUSE’S EMPLOYER: ______________________________________________WORK PHONE: ________________________

EMERGENCY CONTACT: _____________________________________________HOME PHONE: ________________________

RELATIONSHIP: _______________________ _CELL PHONE:________________WORK PHONE: ________________________

RESPONSIBLE PARTY INFORMATION IF DIFFERENT THAN ABOVE:

NAME: ________________________________________________________SOC. SEC. # _________-_______-___________

RELATIONSHIP TO PATIENT: _________________________________________________HOME PHONE: ________________

ADDRESS: ______________________________________________________________________________________________

EMPLOYER: ______________________________________________OCCUPATION: __________________________________

EMPLOYERS ADDRESS: _____________________________________________________WORK PHONE: ________________

PRIMARY INSURANCE COMPANY: __________________________________________________________________________

ID #: ________________________GROUP #________________________POLICYHOLDER: __________________________

SECONDARY INSURANCE COMPANY: _______________________________________________________________________

ID #: ________________________GROUP # ________________________POLICYHOLDER: __________________________

AUTHORIZATION TO RELEASE INFORMATION

I HEREBY AUTHORIZE UROLOGY GROUP OF NEW MEXICO, P.C. TO FURNISH INFORMATION TO MY REFERRING PHYSICIAN AND/OR TO INSURANCE CARRIERS CONCERNING MY DIAGNOSIS AND TREATMENTS.

SIGNATURE: ___________________________________________________ DATE: ____________________________

ASSIGNMENT OF BENEFITS AND AGREEMENT TO PAY:

I HEREBY AUTHORIZE PAYMENT DIRECTLY TO UROLOGY GROUP OF NEW MEXICO, P.C. FOR THE SERVICES RENDERED BY THEM. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO THE DOCTORS FOR CHARGES NOT COVERED BY THIS AUTHORIZATION. THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS CUSTOMARY TO PAY FOR ALL SERVICES WHEN RENDERED, UNLESS ARRANGEMENTS ARE MADE IN ADVANCE.

SIGNATURE: __________________________________________________ DATE: ___________________________

[pic]

[pic]

• Getting plenty of rest

• Limiting yourself to light activity until you heal

You should feel back to normal within a couple of weeks.

Is it okay to take medicine?

Don't take aspirin, ibuprofen (brand names: Advil, Motrin, Nuprin), ketoprofen (brand name: Orudis) or naproxen (brand name: Aleve) for 2 weeks before or after the operation. All of these can thin your blood and cause bleeding. Try acetaminophen (brand name: Tylenol) to relieve pain.

When can I go back to work?

If you have a desk job, expect to return to work after a couple of days. If you do physical labor, or walk or drive a lot, talk with your doctor about when you can go back to work.

Will the vasectomy work right away?

No. You'll need to ejaculate as many as 15 to 20 times before the sperm will be cleared from both the vas deferens. For that reason, keep using birth control. Your doctor will ask you to bring in samples of your ejaculation after the operation. Only after you have a sperm-free sample will you be considered unable to get a woman pregnant. This may take 3 months or longer.

What are the risks of a vasectomy?

Problems that might occur after your vasectomy include bleeding, infection and a usually mild inflammatory reaction to sperm that may have gotten loose during the surgery (called sperm granuloma). Call your doctor if you notice any of the signs in the box below.

Another risk is that the ends of the vas deferens may find a way to create a new path to one another. This doesn't occur very often. But if it does, you could be able to cause a pregnancy.

Call your doctor if:

• You have a fever.

• You have swelling that won't go down or keeps getting worse.

• You have trouble urinating.

• You can feel a lump forming in your scrotum.

• You have bleeding from an incision that doesn't stop even after you've pinched the site between 2 gauze pads for 10 minutes

What happens to the sperm?

Once sperm can't get through the vas deferens, your testicles will begin making fewer sperm. Your body will absorb the sperm that are made.

[pic]

[pic]

|[pic] | | |MEDICATIO| | | |

| | | |N LIST | | | |

|Include all herbal or homeopathic medications. Do you take aspirin? Y N | |Do you take aspirin? |Y |N | | |

|Pharmacy Name:_________________________________ Pharmacy Phone ______________________ |Pharmacy Phone:____________________ | |

DRUG DOSAGE(MG) TIMES PER DAY |Dosage (mg) |Times per day |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  | |Patient Name: |  |  |  |  |  |  |  |  |  |  | |

INSTRUCTIONS FOR VASECTOMY PATIENTS

1. On the evening prior to or on the morning of your vasectomy appointment, completely remove all hair from the scrotum and half way up the base of the penis. This should be done by shaving. We suggest you use a hair trimmer first to get the hair short (use a short number one guard), then dry shave with a straight or blade razor, NOT an electric razor. A soap and water shave also works. After shaving, wash the penis and scrotum thoroughly then shower to remove all loose hair. Do not take aspirin or Coumadin for one week prior to the procedure.

2. If your appointment is in the morning, eat only a light breakfast. If it is in the afternoon, eat breakfast and only a light lunch.

3. A responsible adult with a driver's license should accompany you to take you home after your appointment.

4. Make sure you bring a clean (or new) athletic supporter to the appointment. A “cup” is not needed.

5. We will make arrangements to see you for a wound check with in one (1) week following your vasectomy. Until you are seen, you should restrict your activity to a minimum. Under no circumstances should you engage in any strenuous physical activity. Should any oozing of blood from the incision occur during your early post-op period, grasp some skin around the vas opening and pinch the area for 10 minutes then apply ice packs to the site. If bleeding persists or swelling occurs, contact the doctor at the office or through the answering service.

6. A number of ejaculations, within several weeks following surgery, are required to empty the seminal vesicles of residual spermatozoa. Therefore, you should have frequent sexual intercourse during the weeks following the vasectomy. A sperm check will be done at 12 weeks after the vasectomy. If further sperm checks are necessary, they will be done at monthly intervals. MAKE SURE TO USE CONTRACEPTIVES UNTIL THE SPERM COUNTS HAVE BEEN PERFOMED.

7. You will be informed when you have a total absence of sperm in your specimen. ONLY THEN CAN YOU SAFELY ABANDON YOUR PRESENT BIRTH CONTROL METHOD.

Failure to cancel 48 hours prior to scheduled vasectomy will result in $200.00 cancellation fee

For more information, please call our office.

11/14/14

UROLOGY GROUP OF NEW MEXICO, PC

FINANCIAL PAYMENT POLICY

Dear Patient,

REGARDING INSURANCE: The doctor's service is provided directly to you and you are

responsible for payment of these services. We do not provide service on the assumption

that charges will be paid by your insurance company. If we are not participating providers

with your insurance company, we require that payment be made at the time services are

rendered. As a courtesy to our patients, we will submit a claim to your insurance

company for you.

Our office participates with most Medicare senior plans and many managed care insurance

companies. Should your insurance coverage be with one or more of these companies,

we will bill your insurance company, based on the guidelines of our contract. Co-payments

and deductibles that have not been satisfied are required at the time services are rendered.

If required by your insurance plan, it is your responsibility to obtain a proper referral from your primary care physician. If you do not secure a proper referral for the services provided, charges may be your responsibility.

In order fully to evaluate your symptoms, Urology Group of New Mexico may perform an ultrasound or an office procedure on you in additional to the office consultation. These procedures may be performed with or without local anesthesia, and they will allow for further assessment of your complaint.

If this occurs, there will be a charge for the office visit and a charge for the procedure being done. Some insurance companies may apply the co-pay to the office visit and apply the charge for the procedure toward your deductible. Your signature below indicates that you understand the information listed above, all financial questions have been answered, and that you give Urology Group of New Mexico permission to perform these procedures when necessary, today or during any future appointments. If you have any questions about the cost of these procedures, or if you do not know your insurance benefits, please contact us.

If a surgical procedure is performed, our office needs to collect any co-pays or deductibles prior to your procedure. We will bill your insurance company directly and withhold any further action for forty-five days. We strongly encourage you to get involved with the insurance company’s payment process.

Informing our patients about our financial policy assists us in providing the best services

to our patients. Thank you for taking the time to read this policy statement. Should

you have further questions or comments; please contact our billing staff or manager.

WE ARE HERE TO HELP YOU!

I understand and agree to comply with this financial policy:

___________________________ ___________________

Signature Date

UROLOGY GROUP OF NEW MEXICO

CANCELLATION POLICY (Effective 12/01/10)

It has become necessary for us to institute a 48 hour cancellation policy. We will now charge for all missed and canceled appointments without a 48 hour notice. Canceling the day of the scheduled appointment and/or “failing to show up” will result in incurring a charge.

$200.00 failed to show/late cancel appointment for a vasectomy.

This courtesy, on your part, makes it possible for us to give the appointment time to another patient who desires to be seen by us. We do understand situations arise but please notify us so that we can accommodate other patients as soon as possible.

As a courtesy to our patients, we do try to confirm all appointments 48 hours in advance. However, this is a courtesy. If for some reason we fail to reach you the responsibility for keeping your appointment lies with you.

Thank you for your understanding.

________________________________________ ________________

Patient’s Signature Date

Assignment of Insurance Benefits

I hereby authorize direct payment to Urology Group of New Mexico of any insurance benefits otherwise payable to me or on my behalf for services performed by Urology Group provider. I understand that my insurance is billed as a courtesy and I am financially responsible for all charges not covered by this assignment of benefits.

Authorization for Release of Information

I authorize Urology Group of New Mexico to release medical information concerning my care and treatment to my primary care provider or to the third party payers for the purpose of processing claim payment.

Collection Agency Accounts

In the event that this account is placed with a collection agency, I agree to be responsible for the collection fees, reasonable attorney’s fees, and court costs.

My signature acknowledges the understanding and acceptance of all of the above policy statements.

X_______________________________ _________________________

Parent or Guardian Signature Date

HIPAA

I acknowledge that I have been given an opportunity to review and/or have received a copy of the notice of privacy policies as required by HIPAA. I may contact the office for questions or complaints regarding these privacy rights. The practice will offer updates for any amendments or changes.

I also authorize my physician and his/her staff to communicate information regarding appointments, medical result, and billing issues to:

Print Name ______________________________

Relationship _____________________________

X_____________________________ __________________

Patient or Guardian Signature Date

X_____________________________ ____________________

Witness Date

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download