GILLESPIE COUNTY UROLOGY
IF PATIENTS INSURANCE IS NOT THROUGH EMPLOYER OR PATIENT IS A MINOR, PLEASE COMPLETE THIS SECTION.
Prescription Refills
Telephone prescription refills must be requested on Monday – Friday between the hours of 8:30 am and 4:00 pm. Please allow 24 – 48 hours for your prescription to be called in. Prescriptions will not be called in after hours or on weekends
Notice of Privacy Practices Acknowledgment- By my signature below, I acknowledge receipt of the Notice of Privacy Practices.
We keep a record of the health care services we provide you. You may ask to see and copy that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting the Clinic Administrator. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Office Use Only
*You must sign and date the bottom of the page to be a patient at Gillespie County Urology.PAYMENT OF BALANCES IS DUE IN FULL AT TIME OF SERVICE unless other arrangements have been made in advance by either you or your health insurance carrier. We accept Visa, MasterCard, Discover,American Express, Checks and Cash.
I hereby authorize Michael C. Speck, M.D., P.A. to furnish my insurance company with all the information that they may request concerning my present illness or injury. I assign Michael C. Speck, M.D., P.A. all money to which I am entitled for medical expenses related to the service reported. I understand that I am financially responsible to Michael C. Speck, M.D.,P.A. for charges not covered by this assignment. If I do not pay my balance, I will be sent to collections in 90 days. I understand that I may be eligible to set up a payment plan. I understand that I can be fired from Michael C. Speck, M.D.,P.A. for not paying my balance.
I have read and understand the above financial policy/office agreement of the practice, and I agree to be bound by all its terms. I also understand and agree that the practice may amend such terms from time to time.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
If you have questions about your insurance coverage, please call the phone number on the back of your insurance card.
If NO, please list your Authorization for persons to whom information may be disclosed below:I AUTHORIZE MICHAEL C. SPECK, M.D., P.A. TO DISCUSS AND/OR RELEASE MY PROTECTED HEALTH INFORMATION,INCLUDING LABS, TEST RESULTS, DIAGNOSIS AND TREATMENTS DISCUSSED TO THE FOLLOWING PERSONS:
Allergies:
Medications:
Surgical History
Medical History
Family History
Social History (Select One)
Review of Systems: Urinary Symptom(s) are:
What is your:
Your information will be encrypted.