Urology New Patient

Caring Hearts and Healing Hands

The Crescent approach to urologic care.

Insured Information
Person Who Carries Insurance

First NameLast Name
Relationship to Patient
Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Insured Home
Insured Cell
Insured Work
Insured Email
example@example.com
Relationship

PatientParent/guardianOther

Consent of Treatment
I hereby authorize such medical care, treatment, and diagnostic tests as may be recommended and understand there is no warranty or guarantee of result or cure. This consent will remain in effect until I withdraw my consent in writing. I understand that medical students, under supervision, may be involved in my care.
Consent of Treatment*

YesNo

Acknowledgment of Receipt of Office & Financial Policy
Our patient financial policy is designed to ensure transparency, clarity, and fairness in managing financial matters related to healthcare services. Upon request, patients will be issued comprehensive billing statements detailing the services provided and associated costs. It is the responsibility of the patient to carefully review these statements for accuracy and to address any concerns promptly with our billing department. We accept payment for services rendered and various payment methods, including credit/debit cards, checks, and cash.Office payment is due at the time of service unless your health insurance carrier has mad prior arrangements.

I acknowledge that I have received the Office and Financial Policy for ODR Pediatric Urology Institute and agree to its terms.
Acknowledgment of Financial Policy*

YesNo

Authorization to Leave Recorded Voice Massages
I hereby give my permission for ODR Pediatric Urology Institute Physicians and Staff to leave messages regarding office visits and appointments as well as any other medical information related to my treatment at the phone number(s) listed below:
Authorize Recorded Voice Messages*

YesNo

Acknowledgement of Receipt of Joint Notice of Privacy Practices
This Joint Notice of Privacy Practices applies to the privacy practices of the Affiliated Entities and the Entities participating in the Organized Health Care Arrangement. These Entities include: ODR Pediatric Urology Institute Insurance Co., Ltd., Physicians and Allied Professionals with privileges to practice ODR Pediatric Urology Institute Healthcare Facility.

This form is used to document (a) an individual acknowledgement of receipt of our Joint Notice of Privacy Practices or (b) when we have not obtained this acknowledgment, our good faith effort to obtain the acknowledgment.
Self or Representative*

IndividualRepresentative
SECTION A: The Individual

SECTION B: Acknowledgement of Receipt of Joint Notice of Privacy Practices.

I acknowledge that I have received a Joint Notice of Privacy Practices from ODR Pediatric Urology Institute Healthcare System.
Individual Acknowledge of Privacy Practices

YesNo
If this acknowledgement is signed by a personal representative on behalf of the individual, complete the following:

Personal Representative’s Name: Relationship to Individual:

SECTION C: Good Faith Effort to Obtain Acknowledgment of Receipt
Describe your good faith effort to obtain the individual’s signature
Describe the reason why the individual would not/could not sign this form
Representative Acknowledge of Privacy Practices

YesNo

Assignment of Benefits
I acknowledge full responsibility for the payment of services received and agree to pay them in full at the time of service unless other arrangements have been made. I understand that insurance coverage is an arrangement between the insurance carrier and the patient. ODR Pediatric Urology Institute will assist in billing my insurance company, but I am ultimately responsible for payment should my insurance fail to pay within a reasonable amount of time.

I authorize ODR Pediatric Urology Institute to bill my insurance or third-party payer and receive payment directly from them for services rendered. I also authorize ODR Pediatric Urology Institute to release information as required to my insurance or third-party payer (including my employer’s worker’s compensation carrier), for the purpose of determining benefits. I understand that such records may include information regarding HIV/AIDS testing, substance abuse and/or mental health issues. A photocopy or a faxed copy of this authorization shall be deemed as valid as the original.

My signature signifies acceptance of all terms in this assignment of benefits.
Authorize Assignment of Benefits*

YesNo

Authorize For Use and Disclosure of Protected Health Information
I hereby authorize:
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Practice
Practice Address

Street Address

Street Address Line 2

CityState

Zip Code
Practice Phone
Practice Fax
to disclose certain protected health information (PHI) about me to:

Crescent Urology Institute

1200 Binz St. Ste 690

Houston, TX 77004

Medical Records Tel: 713-366-7831

Medical Records Fax: 832-753-7949

Information to be released: My Complete Medical Record - or -
HIV/AIDS: Consent to the release of any positive or negative test result for AIDS or HIV infection, antibodies to AIDS, or infection with any other causative agent of AIDS, with the rest of my medical records.

The information will be used or disclosed for the following purpose: Transfer of my urologic care to Crescent Urology Institue.

If requested by the patient, purpose may be listed as “at the request of the individual.” The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire two years from the last date of service visit. A photocopy or electronic copy of this form will be considered valid as the original.

I do not have to sign this authorization in order to receive treatment from the Practice. I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at the ODR Pediatric Urology Institute.
HIV/AIDS Release Consent*

YesNo
Health Information Disclosure Consent*

YesNo
Authorization granted by*

First NameLast Name
Consent Signature*

Clear
Relationship to Patient*

SelfParent/GuardianOther
Signature Date*

MonthDayYear

Designation of Personal Representatives
Under the provisions of the Health Insurance Portability and Accountability Act (HIPAA) that became effective on April 14, 2003, health care providers and their staffs are limited in the information that they may share with individuals other than the patient or his/her parent or guardian. In many cases, patients would like to involve a member of their family or another person in management of their health care. Such disclosures of information are permitted by HIPAA when the patient (or his/her parent or guardian) designates an individual(s) as his/her Personal Representative. Therefore, if you would like to designate one or more individuals to serve you as your Personal Representative, please complete the information below.
I, the patient/parent/guardian hereby designate the individual(s) listed below to serve as my personal representative(s) or the personal representative of the name above. By designating this individual(s) as my personal representative, I am giving permission to the physicians and the staffs of the Crescent Urology Institute to discuss any information pertaining to my health care, (including appointments, diagnoses, treatment plans, insurance information, and other related topics).

This designation will remain in effect until such time as I revoke it in writing.
Representative(s)

Individual #1Individual #2Individual #3
Rep. #1 Name

First NameLast Name
Rep. #1 Email
example@example.com
Rep. #1 Phone Number

Area CodePhone Number
Rep. #1 Address

Street Address

Street Address Line 2

CityState

Zip Code
Rep. #2 Name

First NameLast Name
Rep. #2 Email
example@example.com
Rep. #2 Phone Number

Area CodePhone Number
Rep. #2 Address

Street Address

Street Address Line 2

CityState

Zip Code
Rep. #3 Name

First NameLast Name
Rep. #3 Email
example@example.com
Rep. #3 Phone Number

Area CodePhone Number
Rep. #3 Address

Street Address

Street Address Line 2

CityState

Zip Code

Patient History
Current Problem
Problem Began Date

MonthDayYear
Primary Care Physician

First NameLast Name
Other Physician

First NameLast Name
Medication/Drug Allergies:
Are you allergic to any medications? *

YesNo
If yes, allergic drug name and reaction
Latex Allergy?*

YesNo
Previous Surgeries*

YesNo
Surgery Date

MonthDayYear
Date
Surgery
Surgery Date

MonthDayYear
Date
Surgery
Surgery Date

MonthDayYear
Date
Surgery
Habits:
Tobacco Use*

YesNo
Tobacco Type and Frequency
Alcohol Use*

YesNo
Alcohol Type and Frequency
Drug Use*

YesNo
Drug Type and Frequency
Caffeine Use*

YesNo
Caffeine Type and Frequency

Family History

	Mother	Father	Grandparent	Brother	Sister	Other
Arthritis, Gout
Asthma, Hay Fever
Breast Cancer
Colon Cancer
Rectal Cancer
Chemical Dependency
Diabetes
Heart Disease, Stroke
High Blood Pressure
Kidney Disease
Tuberculosis
Other

Have you ever had a blood transfusion?*

YesNo
If yes approx. date(s):

MonthDayYear
Women Only:
Date of last menstrual period:

MonthDayYear
Date of last Pap Smear:

MonthDayYear
Date of last Mammogram:

MonthDayYear
Are you pregnant?

YesNo
Number of Children:
Past Medical History:
Please mark if YOU have a “PAST” history of the following:

AIDSAlcoholismAnemiaAnorexiaAppendicitisArthritisAsthmaBleeding DisordersBreast LumpBronchitisBulimiaCancerCataractsChemical DependencyChicken PoxDiabetesEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart DiseaseHepatitisHerniaHerpesHigh CholesterolHIV PositiveKidney DiseaseLiver DiseaseMeaslesMigraine HeadachesMiscarriageMononucleosisMultiple SclerosisMumpsPacemakerPneumoniaPolioProstate ProblemPsychiatricRheumatic FeverScarlet FeverStrokeSuicide AttemptThyroid ProblemsTonsillitisTuberculosisTyphoid FeverUlcersVaginal InfectionsVenereal Disease
Please review the items below and mark a “✓” the symptoms you currently have or have had in the past year:
General

ChillsDepressionDizzinessFaintingFeverForgetfulnessLoss of SleepNervousnessNumbnessSweats
Genito-Utinary

Blood in urineFrequent UrinationLack of Bladder ControlPainful Urination
Endocrine

Heat/Cold IntoleranceExcessive HungerExcessive ThirstExcessive UrinationHormonal Abnormalities
Cardiovascular

Chest PainHigh Blood PressureIrregular HeartbeatLow Blood PressurePoor CirculationRapid HeartbeatSwelling of AnklesVaricose Veins
Musculoskeletal

Arms/HandsLegs/feetNeck/ShoulderBack/Hip
Men Only

Breast LumpErection DifficultiesLump in TesticlesPenis DischargeSore on PenisOther
Skin

Bruise EasilyHivesItchingChange in MolesRashScarsSore that Won’t Heal
Gastrointestinal

Poor AppetiteBloatingBowel ChangesConstipationDiarrheaExcessive HungerGasHemorrhoidsIndigestionNauseaRectal BleedingVomitingVomiting Blood
Women Only

Abnormal Pap SmearBleeding Between PeriodsBreast LumpExtreme Menstrual PeriodsHot FlashesNipple DischargePainful IntercourseVaginal DischargeOther
Eye, Ear and Throat

Bleeding GumsBlurred VisionCrossed EyesDifficulty SwallowingDouble VisionEaracheHay FeverHoarsenessLoss of HearingNosebleedsPersistent CoughSinus ProblemsVision-FlashesVision-Halos

Appointment Late Fee Policy
Your appointment time is reserved specifically for you or your loved ones. While we understand that emergencies and other unexpected situations do arise, please be courteous and contact us one business day prior to your appointment for cancellation /reschedules. Patients are granted with a 15 minutes grace period for the appointment, a $25 late fee out of pocket will be charged at check in for late arrival.

My signature signifies acceptance of all terms in this late fee policy.

Signature
Signature*

Clear
Signature Name*

First NameLast Name
Relationship to Patient*

SelfParent/GuardianOther
Signature Date*

MonthDayYear
Geo Location Stamp
Should be Empty:

Caring Hearts and Healing Hands