PATIENT INFORMATION ACCT# _____________

PLEASE PRINT CLEARLY & FILL OUT COMPLETELY TODAY’S DATE ____/____/____1 PATIENT PERSONAL INFORMATION

PATIENT'S FULL NAME __________________________________________________ Age _______ Date of Birth ____/____/____

U.S. CITIZEN? YES ❒ NO ❒ ❒ Male ❒ Female ❒ Minor ❒ Single ❒ Married ❒ Separated ❒ Divorced ❒ Widowed

Name of Insured _____________________________________________________ Relationship to Patient _______________________

Where Do You Live? ____________________________________________________________________________________________ Number And Street City And State Zip

Where Do You Get Your Mail? ____________________________________________________________________________________❒ Same as Above Number And Street City And State Zip

Home Phone #______________________ Work Phone #_______________________ Pager/Cellular Phone #_____________________

SOCIAL SECURITY NUMBERS: Patient/Guardian # _____________________________ Spouse # ___________________________

Patient/Guardian Occupation ___________________________ Employer _________________________________________________ Name Phone #

Spouse’s Name ____________________ Occupation ______________ Employer _________________________________________ Name Phone #

Primary Physician's Name ______________________________________________ Phone # _________________________________

Has Any Member Of Your Family Ever Been _____________________________________________________ ______/______Treated At This Office? ❒ YES ❒ NO Family Member's Name Month Year

Referred By: ❒ Hospital ❒ Doctor ❒ Employer ❒ Other (Please list name) ___________________________________________

PROBLEM (State Briefly In Your Own Words): ______________________________________________________________________

Have You Been Treated For This Problem __________________________________ ______________________________________By Another Physician? ❒ YES ❒ NO Name Of Physician City State

Was This Problem Caused By An Injury? _____/_____/_____ ____________________________________________________❒ YES ❒ NO Date Of Injury Place Of Injury

Were X-Rays Taken Of Your Injury Or Problem? _____/_____/_____ _____________________________________________❒ YES ❒ NO Date Of X-Rays Place Taken (Hospital, Etc.)2 RESPONSIBLE PARTYWHO IS RESPONSIBLE FOR PAYMENT ON THIS ACCOUNT? ❒ SAME AS ABOVEIf Different Than Above, Please Provide The Following Information:

Name __________________________________________________ Relationship To Patient __________________________________

Date Of Birth ____/____/____ Social Security # ____________________________ Driver's License # __________________________

Current Home Address __________________________________________________________________________________________ Number And Street City And State Zip

Responsible Party's Occupation __________________________ Employer ________________________________________________ Name Phone #

3 TELEPHONE/CONTACTS IN EVENT OF EMERGENCYWhere Do You Prefer To Receive Calls? ❒ HOME ❒ WORK ❒ PAGER/CELLULAR ❒ OTHER _______________________

When Is The Best Time To Reach You? TIME: _________ ❒ AM ❒ PM DAYS: ❒ M ❒ T ❒ W ❒ Th ❒ F ❒ Sat ❒ Sun

Person Whom We May Contact ___________________________________________ ____________________________________In The Event Of An Emergency Name Phone #

Nearest Relative Not ________________________________________________ ____________________________________Living With You Name Phone #

Nearest Friend Not ________________________________________________ ____________________________________Living With You Name Phone #

©1997 G.U.C. P.C

4 INSURANCE INFORMATIONPLEASE BE SURE THE RECEPTIONIST HAS MADE COPIES OF YOUR MEDICARE AND/OR INSURANCE CARDS FOR OUR RECORDS

❒ MEDICARE __________________________ ❒ PART A ❒ RAILROAD RETIREMENT _________________________Number ❒ PART B Number

❒ MEDI-CAL __________________________ Do You Plan To Apply For Medi-Cal? ❒ YES ❒ NO Number

❒ PRIMARY INSURANCE Name Of Insured _________________________________________ Insured's D.O.B. ____/____/____

Relationship To Patient ________________________________ Social Security # ______________________________________

Insured's Occupation __________________________________ Employer ____________________________________________ Name Phone #

Insurance Company _____________________________________________________________________________________________Group # Employee/Cert. #

Deductible $ __________________________________________ Amount Already Met $ _________________________________

❒ SECONDARY INSURANCE Name Of Insured ______________________________________ Insured's D.O.B. ____/____/____

Relationship To Patient ________________________________ Social Security # ______________________________________

Insured's Occupation __________________________________ Employer ____________________________________________ Name Phone #

Insurance Company _____________________________________________________________________________________________Group # Employee/Cert. #

Deductible $ __________________________________________ Amount Already Met $ _________________________________5 AUTHORIZATION AND RELEASE OF MEDICAL INFORMATION

I hereby authorize Dr. __________________________________ to release to Griffith Urology Clinic, P.C. any information regarding his findingsand treatment.

______________________________________________ _____/_____/_____Patient (Or Guardian's) Signature Date

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me ormy child during the period of such care to third party payors and/or other health practitioners. I authorize treatment of the person namedabove and agree to pay all fees and charges for such treatment. I agree to pay all charges for me and members of my family shown bystatements, promptly upon presentment thereof, unless credit arrangements are agreed upon in writing. Charges shown by statements areagreed to be correct and reasonable unless protested in writing within thirty days of billing date. An interest charge of 1.5 % per month(18 % per annum) will be added to my account if there is any unpaid balance after 60 days. In the event legal action should becomenecessary to collect an unpaid balance due for medical services rendered to me or my family, I/we agree to pay reasonable attorney's feesor other such costs as the Court determines proper. It is agreed that payments will not be delayed or withheld because of any insurance coverage or the pendancy of claims thereon, and allproceeds of insurance are assigned to this office where applicable, but without their assuming responsibility for the collection thereof. (Acopy of this assignment is as valid as the original.)NOTICE: Do not sign this agreement before you read and agree to the conditions set forth. You are entitled to a copy of the agreementat the time you sign. Keep it to protect your legal rights.AGREEMENT: The above information is for the purpose of obtaining credit and is warranted to be true. I authorize the creditor or hisagent to make a credit investigation, including employment verification.ASSIGNMENT OF BENEFITS: I hereby authorize payment directly to Griffith Urology Clinic, P.C. of the surgical, medical, and x-ray benefits otherwise payable unto me. I understand I am financially responsible for the charges not covered by this authorization.I hereby acknowledge receipt of a copy of this form.

______________________________________________ _____/_____/_____Patient (Or Guardian's) Signature Date

6 FINANCIAL ARRANGEMENTS

I PLAN TO MAKE PAYMENT OF MY MEDICAL EXPENSES AS FOLLOWS (Check One Or More):❒ CASH ❒ CHECK ❒ I WISH TO DISCUSS THE OFFICE'S PAYMENT POLICY

©1997 G.U.C. P.C.