Patient Registration Online Form

Patient Information:

Last Name:   First:    Middle:

Street:   City:    State:    Zip:

Local Phone:                 Alternate Phone:      

Social Security #: - -

Date of Birth: / /      Age:             Male Female

Marital Status: Single Married Divorced Widowed      Spouse:

Patient's Out-of-State Address:

Street:   City:    State:    Zip:

Patient's Insurance Information:

Primary Insurance:    ID#:      Group#:

         Pol. Sub.:    DOB: / /

Secondary Insurance:    ID#:      Group#:

         Pol. Sub.:    DOB: / /

Patient's Employment Information:

Employer's Name:     Work Phone:

Employer's Address

Patient's Emergency Contact:

Name: (Someone not living with you)    

Relationship:     Phone:

Physicians:

Name of Referring Physician:     Appointment Physician: Edward Herrman, MD G. Austin Hill, MD Alan K. Miller, MD G. Bino Rucker, MD Mark Weintraub, MD Mitchell Yadven, MD E. Henry Amos, MD Ardeshir Hakam, MD Zoltan Mayer, MD Theresa Jenkins, ARNP

How did you find us? Bradenton Herald Herald Tribune Referring MD Family/Friend Web Search ATT Directory Yellow Book Directory Verizon Directory

During your visit, you will be asked:

• If you do not have your insurance card with you, payment of $250 is requested upon check-in.
• Upon checking-in, to pay your insurance co-pay or,
• Upon checking-out, to pay your 20% co-insurance if have NO Medigap Insurance
• Upon checking-out, to pay any out-standing account balance.
• If you’re having an elective procedure (i.e. vasectomy, etc.), to pay upon checking-in.

CASH, CHECK (in-state) or CREDIT CARD (Visa, M.C., Discover, or Am. Exp.) is accepted.

Please provide your current insurance cards, driver’s license & medication list for copying when you check-in.

I authorize my MEDICARE / COMMERCIAL INSURANCE to make their payments directly to UROLOGY
PARTNERS, PA for any services furnished to me. I will be responsible for paying any remaining balance after
insurance pays Urology Partners.