NEW PATIENT PAPERWORK

Please provide your driver's license and insurance cards to the front desk to scan into our system.

Insurance: Please list all insurance.

MEANINGFUL USE DATA (Please select)

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.

FINANCIAL/OFFICE AGREEMENT

*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 agree that the above information is correct. If any of the above information changes, it is my responsibility to notify the Gillespie County Urology office.
• I understand that payment of copayments, deductible, and percentages not covered by my insurance carrier are due upon the receipt of a statement from our office or at time of service, whichever comes first.
• I understand that Michael C. Speck, M.D., P.A. is a Medicare provider and will submit all claims to them.
• If I am a Medicare recipient, I know I will be responsible for annual deductibles, 20% coinsurance, and any charges the Medicare states that I am responsible for.
• I understand it is the responsibility of the guarantor to know the details and benefits associated with their insurance plan or coverage and to obtain all referrals and authorizations from the primary care physician, when applicable. If you do not have a current referral or authorization on file, you may be asked to reschedule your appointment. Also, if a proper referral is not obtained by the time services are rendered, I will be financially responsible for those services.
• Surgery deposits are due 5 business days prior to surgery. If for any reason surgery needs to be cancelled it must be done 10 business days in advance or a $150 cancellation fee may be charged to the patient
• Vasectomies will be paid in full before the procedure and will be reimbursed based off of insurance payment. Vasectomy payment does not cover lab fees. We will submit your insurance information to the lab but you are ultimately responsible for lab fees.
• I understand that Michael C. Speck, M.D., P.A. requires 24-hour cancellation/rescheduling appointment notice. A charge of $15.00 for office visits and $100.00 for procedures will apply without proper notice.
• Upon request, our staff provides an estimate of costs for services. However, the actual cost of services is established according to the level of care needed as determined by your provider at time of service.
• A $25 fee is required for forms completed by physicians. (ex. Disability, FMLA, etc.)
• I understand that a $30 service fee will be applied to all returned checks.
• $25 Fee for Medical Records.
• There is no guarantee that you will see the provider you were originally scheduled with. Without informing you (the patient) our office can move your appointment between our providers schedules.
• Veterns: A claim will be submitted for the veteran by the provider. By signing this Assignment of Benefits, you approve the payment of medical benefits to the provider directly from your Veteran’s health plan third party administrator.
• Self Pay office visit covers the Office Visit and Urinalysis. Procedures (bladder scans, injections, catheter placement, etc.)will be billed Self Pay rates accordingly.

INSURANCE BILLING:

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.

HIPAA Acknowledgement

If NO, Whom, if anyone, do you authorize Gillesie County Urology to discolose your Medical Information?

Allergies:

Medications: It is your responsibility to update our clinic with your medications.

Surgical History

Medical History

Family History

Social History (Select One)

Review of Systems: Urinary Symptom(s) are: