cvilleurology.com - Registration Form

WELCOME FORMS

Complete this before your appointment and your provider can be better prepared during their time with you.
January 24, 2023

Dear

Thank you for making an appointment with Urological Associates, Ltd. Please complete the following paperwork and bring it with you to your appointment. We ask that you arrive at least 15 minutes prior to your appointment time to register. If you are unable to arrive early this could delay your appointment. Our waiting room tends to be chilly in the summer so please dress appropriately.

There is a $25.00 charge for missed appointments or appointments cancelled without 24-hour notice.
If you have any questions, please feel free to call (434)295-0184 or (434)296-1166. Please bring your insurance card(s) and verify your referral if required.

Thank you,

Urological Associates, Ltd
Initial
Welcome to Urological Associates, Ltd.

Patient Information
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient SSN:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile phone number
Please enter a valid phone number.
Gender:

MaleFemale
Marital Status:
Race:
Preferred Language:
Employer:
Occupation:
Work phone:
Please enter a valid phone number.
Referring Physician:
Referring Physician Phone #
Please enter a valid phone number.
Primary Care Physician (if different from referring)
Primary Care Phone #
Please enter a valid phone number.
Patient Phone Numbers:
Primary#

MobileHome
Primary#
Please enter a valid phone number.
Secondary#

MobileHome
Secondary phone number
Please enter a valid phone number.
May we send you appointment reminders via text?

YesNo
Email address
example@example.com
IN CASE OF EMERGENCY, CONTACT
Name:
Relationship:
Home Phone number:
Please enter a valid phone number.
Work Phone number:
Please enter a valid phone number.
Cellphone number:
Please enter a valid phone number.
My medical information may be shared with the following people:
1. Primary Person:
Relationship:
Phone #
Please enter a valid phone number.
2. Secondary Person:
Relationship:
Phone #
Please enter a valid phone number.
Primary Insurance:
Insurance Company Name:
Policy Number:
Subscriber Name:
Date of Birth:

MonthDayYear
Date
Relationship to patient:
Secondary Insurance:
Insurance Company Name:
Policy Number:
Subscriber Name:
Date of Birth:

MonthDayYear
Date
Relationship to patient:
History of Present Illness:

(All information is strictly confidential)
Today’s Date

MonthDayYear
Date
Name
Date of Birth

MonthDayYear
Date
What is the main reason for your visit today?
Location of the problem

AbdomenBackBladderProstateN/AOther
On a scale of 1-10 with 10 being the most severe, enter the number that best describes the problems effect on quality of life?

1

2

3

4

5

6

7

8

9

10

1 is Least severe, 10 is Most severe
When did you first notice the problem?

2 days ago2 weeks ago1 month agoOther
Medical History
List any medical problems
List previous major surgery & date:
List all medications and dosage you are currently taking
Do you take Aspirin or Motrin daily

YesNo
List any drug allergies
Are you a current TOBACCO user?

YesNo
If yes, Type and frequency?
Have you ever used Tobacco products?

YesNo
If yes, Type, frequency, how long, when quit?
Do you drink alcohol?

YesNo
If yes, how much & how often?
Preferred Pharmacy and location
Family History
Patient Name

First NameLast Name
Has anyone in your immediate family (mother, father, siblings, or grandparents) ever had:
Diabetes?

YesNo
If yes, who?
Heart Disease?

YesNo
If yes, who?
Cancer?

YesNo
Relation
Type
Bleeding Disorders?

YesNo
Relation
Kidney Stones?

YesNo
Relation
Review of Systems
Genitourinary: Do you have a recurrent or chronic problem with any of the following:

Urinary incontinenceUrine retentionUrinary FrequencyBlood in urineNighttime urinationPainful urinationSexual Health Issue
Additional Info
Do you have an Advanced Care Plan or Living Will?

YesNo
In the last 12 months have you received: FLU vaccine?

YesNo
Pneumonia vaccine?

YesNo
COVID vaccine?

YesNo
ARE you 50 years old or older? (If No, skip to signature)

YesNo
Have you had a screening COLONOSCOPY?

YesNo
Have you had a screening MAMMOGRAM?

YesNo
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Patient Signature

Clear
Date

MonthDayYear
Date
Urological Associates, Ltd. Financial Responsibility, Assignment of Benefits, and Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations
I, First Name Last Name ,hereby consent to treatment by Urological Associates, Ltd. Physicians and their assistants and accept responsibility for such fees for such medical services not covered by my insurance. I also understand that as part of my health care, Urological Associates Ltd. originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care and treatment
- A means of communication among the many health professionals who contribute to my care,
- A source of information for applying my diagnosis and surgical information to my bill
- A means by which a third-party payer can verify that services billed were provided, and
- A tool for routine healthcare operations such as assessing quality and review the competence of healthcare professionals
I understand and have been provided with a Privacy Policy that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to review the notice prior to signing this consent
- The right to object to the use of my health information for directory purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations
I understand that Urological Associates, Ltd. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already acted in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by section 164.506 of the Code of Federal Regulations.
I wish to have the following restrictions to the use or disclosure of my health information:
I understand that as part of this organization’s treatment, payment, or health care operations. It may become necessary to disclose my protected health information to another entity, and I consent to such a disclosure for these permitted uses, including disclosure via fax.

Statement of Accidental Body Fluid Exposure
I understand that if healthcare workers are accidentally exposed to my blood or body fluids while providing healthcare to me. I agree to have my blood tested for any infectious disease, which might be transmitted to them through this exposure including HIV/AIDS and hepatitis.

Statement of Financial Responsibility
I understand that payment is due at the time of service. I hereby authorize the release of any information necessary for filing a claim for payment with my insurance company of records. I also authorize payment for services rendered be made directly to the physician(s) providing the service. This authorization is valid for current and subsequent treatment unless I submit a written revocation. I will advise Urological Associates, Ltd. of any changes in insurance coverage. Outstanding debt past 90 days will be referred to a collection agency. Collection fees of 35% will be added to the outstanding debt as well as all attorney fees incurred during the collection process.

Missed Appointment Fee
I understand that if I do not show up for a scheduled appointment or cancel an appointment with less than 24 hours’ notice I will be responsible for paying a $25.00 missed appointment fee.

Statement to permit payment of Medicare / Medicaid benefits to provider
I request that payment of authorized Medicare/Medicaid benefits be made on my behalf to Urological Associates, Ltd. for any services furnished me by that Provider. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare/Medicaid assigned cases, the physician or supplier agrees to accept the charges determination of the Medicare/Medicaid carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare/Medicaid carrier.

Statement to permit payment of Medigap benefits to provider
I request that payment of authorized Medigap benefits be made on my behalf to the Provider for any medical services furnished to me by that Provider.

Additional Fee
I understand that if I have Aetna, Anthem/BCBS, Cigna and Tricare insurance, I may be subject to an additional $6 fee for a blood draw.
I fully understand and accept the terms of this consent
Patient’s Signature (Parent’s if Minor)

Clear
Date

MonthDayYear
Date
Driving directions to:
Urological Associates, Ltd 155 Riverbend Drive Charlottesville, VA 22911 434-295-0184

Coming West on 250
- As you come into Charlottesville on 250, you will pass several car dealerships on your left and right.
- Just past the dealerships you will come to a stop light at the intersection on RT 20 and Riverbend Drive.
- Turn left onto Riverbend Drive
- Our building is directly across from Taco Bell
- Go to the stop light, make U turn, turn right into the 1st Entrance on the right, we are the light tan brick building to the right, park in front of the building
Coming East on 250 or North on RT 29
- Follow RT 250E to Pantops area
- You will pass the Park Street and Locust Ave Exits
- Stay straight at the next stop light across Free Bridge
- Turn right at the next stop light at the intersection of RT 20N and Riverbend Dr
- Our building is directly across from Taco Bell
- Go to the stop light, make U turn, turn right into the 1st Entrance on the right, we are the light tan brick building to the right, park in front of the building
Coming East or West on Interstate 64 – (please be aware of NEW traffic pattern)
- Take Exit #124 (Shadwell)
- Turn onto RT 250 West
- As you come into Charlottesville on 250, you will pass several car dealerships on your left and right.
- Just past the dealerships you will come to a stop light at the intersection on RT 20 and Riverbend Drive.
- Turn left onto Riverbend Drive
- Our building is directly across from Taco Bell
- Go to the stop light, make U turn, turn right into the 1st Entrance on the right, we are the light tan brick building to the right, park in front of the building
Coming South on RT 29
- Take the RT 250E to Richmond Exit
- Follow RT 250E to Pantops area
- You will pass the Park Street and Locust Ave Exits
- Stay straight at the next stop light, across Free Bridge
- Turn right at the next stop light at the intersection of RT 20N and Riverbend Dr
- Our building is directly across from Taco Bell
- Go to the stop light, make U turn, turn right into the 1st Entrance on the right, we are the light tan brick building to the right, park in front of the building
Initial
Initial

WELCOME FORMS

Welcome to Urological Associates, Ltd.

History of Present Illness:

Medical History

Family History

Review of Systems

Additional Info

Bladder & Bowel Symptom Questionnaire