PATIENT INFORMATION
Patient Name Last
First
 Middle
 Account Number
Date of Birth (XX/XX/XXXX)
Home Address
City
 		State
 		Zip
Mailing Address (if different from above)
 		City
 		State
 		Zip
Daytime phone
 Evening phone
Sex Male
Female 		Marital Status: Single Married
Widowed Divorced Separated
Spouse's name:
 Healthcare Proxy
Yes No
Social Security Number (SSN)
 		Driver's License #
 		E-mail address (optional)
Who Referred You? If a physician, give full name and phone number, also.
EMPLOYMENT INFORMATION
Employed Yes
No 		Employer (Parent's employer if minor)
Occupation
Employer Address
City
 		State
 		Zip
Spouse's Employer
Social Security Number (SSN)
Employer Address
City
 		State
 		Zip
height=25>RESPONSIBLE PARTY INFORMATION
Person Responsible for Medical Expenses
 Relationship to patient
 Home Phone
Social Security Number

Work Phone
Address
City
 		State
 		Zip
Payment for Today's Visit
 Name on Card
 Expires
PRIMARY INSURANCE INFORMATION
Insurance Company
 Policy Number
 Medicare Number
 Medicaid Number
Subscriber's Name
 Subscriber's Relationship to Patient:
Self Spouse Parent Other
Date of Birth (XX/XX/XXXX)
 		Social Security Number (SSN)
Address of Insurance Company
 		City
 		State
 		Zip
height=25>SECONDARY INSURANCE INFORMATION
Insurance Company
 Policy Number
 Medicare Number
 Medicaid Number
Subscriber's Name
 Subscriber's Relationship to Patient:
Self Spouse Parent Other
Date of Birth (XX/XX/XXXX)
 		Social Security Number (SSN)
Address of Insurance Company
 		City
 		State
 		Zip
EMERGENCY INFORMATION
Person to Contact in Case of Emergency, Other than Spouse
 Relationship to Patient
 Phone
AUTHORIZATION

All professional services rendered are charged to the patient and remain the patient's responsibility regardless of insurance coverage. It is customary to pay for services when rendered unless other arrangements have been made in advance.
HMO & PPO PATIENTS: It is the patient's responsibility to have any required referral from the primary care doctor and to furnish complete insurance information for this office. If the insurance information or referral is not available, the patient will be responsible for the charges and payment in full will be collected.

AUTHORIZATION AND ASSIGNMENT (PLEASE READ AND SIGN)
I authorize you to give me reasonable and proper medical care by today's standards.
I authorize Dallas Urology Associates, LLP to obtain any X-ray films or laboratory results needed for my treatment.
I authorize Dallas Urology Associates, LLP to release all medical information required by my insurance company and others to file for medical benefits or otherwise collect on my account. I also authorize Dallas Urology Associates, LLP to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I authorize payment of all benefits to the physician(s).

Patient's Signature
Patient Signature Date
 Legally Responsible
Person's Signature
 Date

IMPORTANT:
Before clicking on the below send button that
will submit this form to our office electronically,
PLEASE PRINT OUT THIS PAGE.
Be sure to bring it to your appointment.