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SOUTHEASTERN UROLOGICAL
C e n t e r, P. A .
DATE
PATIENT DEMOGRAPHIC / INSURANCE FORM
NAME _______________________________________________________________________________________________________
LAST FIRST M.I. MAIDEN NICKNAME
SEX: _______ DATE OF BIRTH: _______________________ S.S.# __________________________________________________
ADDRESS: ___________________________________________________________________________________________________
STREET CITY STATE ZIP CODE
PHONE: Home ______________________________________________ Work: __________________________________________
EMPLOYER: ________________________________________________________________________ ! Full Time ! Part Time
ARE YOU A STUDENT? ! Yes ! No ! Full Time ! Part Time
WHO IS YOUR PRIMARY CARE PHYSICIAN? _____________________________________________________________________
SPECIALTY OF PRIMARY CARE PHYSICIAN: _____________________________________________________________________
In the event you have a procedure performed, this information is required by the State of Florida and will be reported
to the agency for Heath Care Administration.
Please complete the following:
1 ! American Indian / Eskimo / Aleut 3 ! Afro-American 5 ! White Hispanic 7 ! Other
2 ! Asian or Pacific Islander 4 ! White 6 ! Black Hispanic 8 ! No Response
MARITAL STATUS: 1 ! Single 2 ! Married 3 ! Divorced 4 ! Widowed
INSURANCE INFORMATION
PRIMARY INSURANCE COMPANY:_________________________________________________________
COMPANY ADDRESS: ________________________________________________________________________________________
STREET CITY STATE ZIP CODE
SUBSCRIBER (POLICY HOLDER) _________________________________________ POLICY HOLDER BIRTHDATE _________
POLICY NUMBER ________________________________ GROUP NUMBER: __________________________________________
POLICY TYPE: ! INDIVIDUAL ! GROUP ! SUPPLEMENTAL ! OTHER __________________________________
POLICY TYPE:PATIENT RELATIONSHIP TO SUBSCRIBER (POLICY HOLDER) ________________________________________
SECONDARY INSURANCE COMPANY: _____________________________________________________
COMPANY ADDRESS: _________________________________________________________________________________________
STREET CITY STATE ZIP CODE
SUBSCRIBER (POLICY HOLDER) _________________________________________ POLICY HOLDER BIRTHDATE _________
POLICY NUMBER ________________________________ GROUP NUMBER: __________________________________________
POLICY TYPE: ! INDIVIDUAL ! GROUP ! SUPPLEMENTAL ! OTHER __________________________________
POLICY TYPE:PATIENT RELATIONSHIP TO SUBSCRIBER (POLICY HOLDER) ________________________________________
PLEASE PRESENT INSURANCE CARD(S) TO THE RECEPTIONIST
Form 0316 (Rev. 09/19/03)
EMERGENCY CONTACT:
NAME ___________________________________________________________ RELATIONSHIP: __________________________
FIRST MIDDLE LAST
ADDRESS: ___________________________________________________________________________________________________
STREET CITY STATE ZIP CODE
PHONE: Home _____________________________________________ Work: __________________________________________
CONSENT TO OUTPATIENT CARE:
While I am a patient at Southeastern Urological Center, I permit my doctor and the employees of Southeastern Urological
Center to perform examinations, diagnostic tests, medical and surgical treatment deemed necessary for my care.
I UNDERSTAND AND AUTHORIZE THE FOLLOWING:
1. Medical and/or demographic information may be released to my insurance carriers for the purpose of filing this
or any future medical claim.
2. I consent to treatment necessary for the care of the above named patient.
.A.
3. I acknowledge full financial responsibility for services rendered by Southeastern Urological Center, P and
authorize transfer of all unpaid amounts to my Visa/MasterCard after 120 days from the date of service for any
dollar amount below _________________. Visa/MasterCard # _________________________________________
4. I understand that payment of charges incurred is due at the time of service unless other definite financial
arrangements have been made prior to treatment.
5. I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of my charges.
6. I further authorize and request that insurance payments be made directly to Southeastern Urological Center, P.A.
should they elect to receive such payment.
7. I have read and fully understand the above consent for treatment, financial responsibility, release of medical
information, and insurance authorization.
___________________________________________________________________ _____________________________________
Signature of Patient / Legal Representative Date
I also authorize Southeastern Urological Center to provide medical information, including that related to HIV testing/
diagnosis/treatment, sexually transmitted diseases, mental health, and drug/alcohol abuse to medical providers I
have been referred by or may be subsequently referred to. I understand that this information may be transmitted via
fax machine to expedite continuity of care.
___________________________________________________________________ _____________________________________
Signature of Patient / Legal Representative Date
I request that payment of authorized Medicare/Other insurance company benefits be made either to me or on my behalf to
___________________________________________________________ for any services furnished me by the party/physician
who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be
responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides
penalties for withholding this information.) Regulations pertaining to Medicare assignment of benefits apply.
I authorize any holder of medical or other information about me to release to the Social Security Administration and
Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information
needed for this or a related Medicare/Other insurance company or a related Medigap claim. I permit a copy of this
authorization to be used in place of the original.
___________________________________________________________________ _____________________________________
Signature Date
Form 0316 (Rev. 09/19/03)
