Segua.com

Southeast Georgia Urology Associates
PATIENT INFORMATION FORM
Preferred Urology Office Location:
Sex: Male
Race: White Black
Preferred Pharmacy:____________________________ Phone:__________________ Fax:__________________ City:________________________ State:_______ Zip:___________ Reason for Appointment today (Chief Complaint) PRIMARY
INSURANCE
: SECONDARY INSURANCE
Please deliver or fax completed form to our office prior to your appointment. Fax number: 912.261-1847

Southeast Georgia Urology Associates
MEDICAL AND SOCIAL HISTORY
Please circle all that apply, write in any additional items not listed. If None apply, please circle „None‟
Marital Status:
Smoking History:
Alcohol Use:
Do you drink coffee?
If so, how much?
Do you drink tea?
If so, how much?
Do you drink soft drinks? Yes
If so, how much?
Do you eat chocolate?
If so, how much?
Are you on a special diet? (If yes, describe)
Occupation:
Significant Family Medical History:
Current Medications:
MEDICATION
DOSAGE
TIMES A DAY
DATE YOU STAR TED THIS
MEDICATION
Southeast Georgia Urology Associates
Allergies:
If none…. Please write in “NONE”
Major Surgeries: If none…. Please write in “NONE”
Major Injuries: If none…. Please write in “NONE”
Southeast Georgia Urology Associates
REVIEW OF SYSTEMS
Constitutional
Gastrointestinal
Genitourinary
Cardiovascular
Respiratory
Allergic Immunologic
Integumentary
Hematologic/Lymphatic
Neurological
Ear Nose Throat
Psychologic
Are you generally satisfied with your life Endocrine
Musculoskeletal
By signing below I acknowledge that all information on this document is true and complete to the best of my knowledge, and that I understand that this information may be related to my insurance company(s) for processing. Southeast Georgia Urology Associates
FINANCIAL, INSURANCE, AND PRIVACY POLICIES
Payment is due at the time of service. However, as a service to our patients, we will be happy to file your primary and secondary insurance for you. At the time services are rendered, the patient is responsible for payment of the portion their insurance company does not normally pay (ie: your deductible, co-payment, and the percent of the bill not generally covered by insurance.) Once the patient’s insurance company has paid their portion, or after we have waited for their payment for 30 days, you will be billed for any remaining charges not yet paid in full. Each insurance company sets different standards for treatment and reimbursement. Although the majority of our charges fall within most insurance companies’ usual customary and reasonable rates, our charges are not based on any one insurance company’s fee scale. The patient is financially responsible for any charges not covered by their insurance. Any medical referral forms, confirmation of insurance coverage, pre-certification, and/or notification of the patient’s insurance company are the patient’s responsibility. The patient is financially responsible for any charges not covered by their insurance due to failure to obtain the appropriate referral forms / pre-certification, or prior insurance company approval. PATIENTS NOT FILING INSURANCE
Patients who do not have insurance, do not have proof of current insurance, or do not want us to file their insurance must pay
the full balance at the time of service, unless other payment arrangements are made in advance of seeing the doctor. If you do not
have insurance, and do not have full payment, please ask to see the office manager before your appointment to make payment
arrangements.
LAB SERVICES / Insurance Coverage
Urine and blood specimens are frequently taken during office visits in our facilities, and these specimens are frequently
forwarded to an outside, certified lab for analysis. Each insurance company sets different standards for which lab tests they will
pay for, and some insurance companies / policies list particular laboratories that they require specimens be sent to receive full
coverage (Medicare has no such requirement). If your insurance policy has such a requirement, it is your responsibility to
notify the nurse and / or office staff in writing before your appointment.
For the convenience of our patients, we accept payment by VISA, MasterCard, checks, and cash.
I have read and agree to the FINANCIAL POLICY above.

INSURANCE AUTHORIZATION
I hereby authorize Southeast Georgia Urology Associates, its physicians and staff to release any information to any insurance
company processing my claim, including the diagnosis and records in the course of my examination or treatment. I hereby
authorize payment directly to Southeast Georgia Urology and/or its physicians of the medical and/or surgical benefits otherwise
payable to me but not to exceed the charges made for such treatment. A photocopy of this document is as valid as the original.
HIPPA AUTHORIZATION
By signing this form I acknowledge that I have been given the opportunity to review the above named office’s Notice of Privacy Practices, and informed I may keep a copy for reference or obtain a copy upon request.

Source: http://www.segua.com/uploads/2/8/9/5/2895769/newpatientform2011b.pdf