Patient Information Form

  • Billing Party Information

    If different from above
  • Assignment of Benefits and Release of Information

  • 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.