Patient Information Form

Name *

First

Middle

Last

Address *

Apt No. *

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Email Address *

Date of Birth *

SSN *

Sex *

Male Female

Marital Status (if applicable)

Single Married Widowed Divorced

Race *

American Indian/Alaskan Native Asian Hispanic/Latino Black/African American White Other

Other

Ethnicity *

Preferred Language *

Employer

Occupation

Address

City

State

Zip Code

Referred by

Phone

Are there any special needs for this patient *

No Yes

Is yes, please explain

Emergency Contact *

Phone *

Relationship *

Billing Party Information

If different from above

Name

First

Middle

Last

Address

Apt. No.

City

State

Zip Code

Home Phone

Cell Phone

Alternate

Date of Birth

Sex

Male Female

SSN

Relationship to the patient

Employer

Occupation

Address

City

State

Zip Code

Assignment of Benefits and Release of Information

May we release medical information to your spouse or family member? *

Yes No

I hereby authorize my insurance carries to pay directly to Rio Grande Urology, P.A., all benefits due to me as provided for in my contract for medical services referred. I understand that regardless of my insurance coverage, I am personally responsible for any debris incurred by me and will pay for all charges in excess of whatever sums are paid for by my insurance company.

Patient Full Name *

Date *

Billing Party Information

Assignment of Benefits and Release of Information

Start your journey

Start your journey