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
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
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

After submitting this form to our office electronically with the button below,
you will see a page with the information you submitted.
Please also PRINT OUT the completed page and bring it to your appointment.