Werner-Francis Urology Assoc llc/MAUA    

7500 HANOVER PKWY  SUITE 206

GREENBELT, MD, 20770

oFFICE USE ONLY

DR#___________OFFI#__________

SIG ON FILE___________________

STATEMENT__________________

INS FORM____________________

 

                             PATIENT INFORMATION SHEET         click here to PRINT NEW PATIENT PACKAGE

I WAS REFERRED TO YOUR OFFICE BY:          DR:______________________________________________

 Friend/Patient___________________Advt__________Yellow Pages______________Other_______________

PATIENT:

_________________________________________________________________________________________________

NAME                                                                                  SS#                                                DOB

 

_________________________________________________________________________________________________

ADDRESS / STREET                                                            CITY                                ST              ZIP CODE

 

(        )            -                                 (        )            -                                 S M D W P             M     F                   

HOME PHONE                                 WORK PHONE                            MARITAL STATUS          SEX 

 

E-mail Address_____________________________________________________________________________________

 

ARE YOU A STUDENT?__Y  N          IF YES, WHERE?_____________________________________

IS THIS CONDITION WORK RELATED         Y     N      AUTO  ACCIDENT RELATED?     Y    N       

IF YOU ARE RETIRED  BUT ARE STILL COVERED BY YOUR FORMER EMPLOYER'S BENEFITS,

PLEASE INDICATE NAME AND PHONE NUMBER OF THAT EMPLOYER

 

                                                                                                                                                                                                                                

EMPLOYER NAME                                                                                                     

                                              (            )-                                         

                                   EMPLOYER PHONE

 

PERSON FINANCIALLY RESPONSIBLE FOR STATEMENTS

 

______________________________________________________________________________________________

NAME                                                                                                 RELATIONSHIP TO PATIENT

______________________________________________________________________________________________

ADDRESS / STREET                                                            CITY                                ST              ZIP CODE

 

(        )            -                                 (        )            -                                                                                         

HOME PHONE                                 WORK PHONE                           SS#

 

IN CASE OF EMERGENCY CONTACT                                                            (            ) -                               

                                                         NAME                                                  PHONE

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PRIMARY INSURANCE COMPANY

                               INTERNAL USE   CODE

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ADDRESS

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CITY/STATE/ZIP

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POLICY HOLDER NAME  (LAST, FIRST)

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RELATIONSHIP                                                                                  CERTIFICATE #

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GROUP #                                                                                           MEMBER #

>>____________________________________________________________________________________________

SECONDARY INSURANCE COMPANY

                               INTERNAL USE   CODE

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ADDRESS

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CITY/STATE/ZIP

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POLICY HOLDER NAME  (LAST, FIRST)

_____________________________________________________________________________________________

RELATIONSHIP                                                                                  CERTIFICATE #

______________________________________________________________________________________________

GROUP #                                                                                           MEMBER #

                                  INSURANCE AUTHORIZATION AND ASIGNMENT

I AUTHORIZE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS ANY INSURANCE  CLAIMS AND I AUTHORIZE PAYMENT OF MEDICAL BENEFITS DIRECTLY TO Werner-Francis Urology Associates/MAUA, FOR MYSELF AND/OR DEPENDENTS.  i UNDERSTAND I AM RESPONSIBLE FOR ANY DEDUCTIBLES, CO-INSURANCE OR AMOUNTS FOR SERVICES NOT COVERED BY THE INSURANCE CARRIER.

_________________________________________________________________________________________________

DATE                                                            SIGNATURE

>>

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OTHER INSURANCE COMPANY

                               INTERNAL USE   CODE

______________________________________________________________________________________________

ADDRESS

______________________________________________________________________________________________

CITY/STATE/ZIP

______________________________________________________________________________________________

POLICY HOLDER NAME  (LAST, FIRST)

_____________________________________________________________________________________________

 

RELATIONSHIP                                                                                  CERTIFICATE #

______________________________________________________________________________________________

GROUP #                                                                                           MEMBER #                              Pg 2

 

 

 

                          Werner - Francis Urology Associates llc - Mid Atlantic Urology Associates llc,   

                        

                                                     Permission to Release Medical Information

                                       Patient:                                               Required by Federal Law

   

I,___________________________________ hereby give permission to Werner - Francis Urology Associates llc - Mid Atlantic Urology Associates llc, Its employees, and sub-contractors to release current, past and future information about my medical condition, diagnoses, treatments and recommendations to:

(Cross out any that do not apply, other than the top six , (in italics), that are required for us to care for you)

  • My present and future health insurers
  • My referring or primary health care provider
  • Other health care providers caring for me
  • Health care providers/laboratories I am referred to
  • Health care facilities I am referred or admitted to
  • Authorized reviewers for regulatory compliance quality assurance and/or peer review
  • My spouse or significant other ______________________________________
  • My parents___________________________________________________________
  • My employer (required for compensation cases)

  • Others ______________________________________________________________

This permission will remain in effect until I revoke all or part of it in writing. I understand that Werner-Francis Urology Associates llc / MAUA will make reasonable efforts to insure my privacy, hut cannot guarantee the conduct of others who receive this information as allowed above. 

Signed_____________________________________________Date____________________

                      Witness_____________________________________________

 Guardian for Dependant:

 I,___________________________________ hereby give permission to Werner - Francis Urology Associates llc - Mid Atlantic Urology Associates llc, Its employees, and sub-contractors to release current, past and future information about

_________________________________________’s, diagnoses, treatments and recommendations to:

(Cross out any that do not apply, other than the top six , (in italics), that are required for us to care for you)

  • His/her present and future health insurers
  • His/her referring or primary health care provider
  • Other health care providers caring for him/her
  • Health care providers/laboratories he/she is referred to
  • Health care facilities he/she is referred or admitted to
  • Authorized reviewers for regulatory compliance quality assurance and/or peer review
  • His/her spouse or significant other__________________________________
  • His/her parents______________________________________________________
  • His/her employer (required for compensation cases)

  • Others ______________________________________________________________

This permission will remain in effect until I revoke all or part of it in writing. I understand that Werner-Francis Urology Assoc llc/MAUA will make reasonable efforts to insure his/her privacy, hut cannot guarantee the conduct of others who receive this information as allowed above.

 Signed_______________________________________Date____________________

 Witness_____________________________________________             Pg 3

 

 

Werner - Francis 

                                                        UROLOGY ASSOCIATES

                                                       STEPHAN L WERNER, M.D.,F.A.C.S.

                                                                   

                                                                        JACK D. FRANCIS, M.D., F.A.C.S.  

                      4000 MITCHELLVILLE RD., STE. A 208                            7500 HANOVER PARKWAY                           7350 VAN DUSEN RD., STE. 350

                        BOWIE, MARYLAND 20716                                              SUITE 206                                                     LAUREL, MARYLAND 20707

                                                      GREENBELT, MARYLAND 20770

                                                        www.wfUROLOGY.com

 301-441-8900

 

            FINANCIAL POLICY

 

                     GENERAL INFORMATION FOR ALL PATIENTS
 

1.  Patients with NO INSURANCE are responsible for payment in full for all services at

the time they are rendered.

2.  Copies of medical records are made free of charge one time with the appropriate

medical records release form. If you are sending your records to another doctor, you

should make a copy for your own records.

3.  Payment for medications, devices, and equipment dispensed from this office is

expected at the time you pick them up. (There are some exceptions to this with

Medicare patients).

4.  As a courtesy to our patients, we do file secondary insurances. However, if we do not

hear from your second insurance within 45 days of our filing a claim, the

responsibility for payment reverts to the patient.

5.  All insurances do not cover all medical problems. If we are notified by your insurance

that we have filed a claim for a non-covered benefit, it becomes patient's responsibility

to make payment.

6.  If you pay by check and the check is returned, there will be a returned check fee of

$25 charged to your account.
 

HMO/PPO INSURANCES

1.  Referrals, including for Out Patient surgery are patient's responsibility. HMO patients

without referrals can do the following:

a)     Pay for appointment. Checks will be held for 48 hrs. and returned to

patient if valid referral is obtained.

b)     Reschedule appointment or surgical procedure.

c)     If referral is not obtained within 48 hrs., patient is responsible for

paying charges for that date of service.

2.  Co-pays are due prior to seeing the physician on the day of appointment. Cash or credit

      card are acceptable forms of co-payment

 

 

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3.  There are some benefits that require a special authorization from your primary care

physician as well as an increased (up to 50%) co-payment. Example: infertility

evaluation and treatment.

4.  Mailhandler's does not pay benefits for sexual dysfunction.

 

MEDICARE

1.  There are some services that Medicare does not pay for. You will be asked to sign a

release for such services indicating that you accept responsibility for payment for

these services.

2.  Our policy with regard to secondary insurance applies to Medigap insurances as well.

 

WORKER'S COMPENSATION

1.  In order for us to accept Worker's Comp insurance, we must have the Case number

and the name and phone number of the case worker or attorney.

2.  In the event that our treatment is considered unrelated to the accident, the patient is

responsible for the balance in full.

 

I have read and fully understand all of the above information,

 

PATIENT (GUARDIAN)         ____________________                  DATE   __________      

 WITNESS (STAFF)________________________                          DATE________             

 

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PATIENT HISTORY FORM

Note: This is a confidential record and will be kept in your doctor's office. Information contained here will not be released to anyone without your authorization to do so.

Todays Date______/        /_______ DATE OF LAST PHYSICAL EXAM ________________

Last Name_________________________First Name____________Middle___________

Social Security #______________________________Date of Birth_________________

Chief Complaint:    What is the main reason for your visit today? (Describe your problem in detail)

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

                          History of Present Illness 

When did you first notice the problem?_________________________________________________________

On a scale of 1-10 how bad is the problem___________How Long does it last?_______________________

Does moving around or changing position make the problem worse?______________________________

Urination: Is uriation painful? Y   N     Do you have to go frequently daytimes?   Y  N  How often?_____

     How many times do you get up at night to go?________Do you ever seen blood in your urine?  Y  N

     Have you had urinary or prostate or bladder infections before?  Y  N   How often__________________

     Is your stream:   Strong    Medium   Weak (circle)  Do you feel empty when you finish?  Y  N

Do you lose urine?    Y  N  (if no, skip to next group)  When you cough or sneeze do you lose urine?  Y  N

    How many times a day or week  ____________________When you have to go is it a mad dash?   Y  N  

    Do you lose it before you get to the bathroom?  Y  N   How many times a day or week?____________

Does the problem interfere with your normal functioning?   Y  N

Physician Use only

 

 Family History: list all serious illnesses in you immediate family (cancer, diabetes, heart disease etc.)

_____________________________________________________________________________________

_____________________________________________________________________________________

Marital Status:  S  M  W  D  Other         Sexual Preference (optional)  Straight, Gay, Bi

Personal History: list all major illnesses, conditions and surgery and approximate year ________________________________________________________________________________________________

________________________________________________________________________________________________

Medications:_(Drug, dose, any over the counter or herbals)__________________________________________

________________________________________________________________________________________________

Allergies:____________________________________________________________________________________

________________________________________________________________________________________________

Do or did you smoke?  Y  N   How much_______ How Long?_________When did stop_________

Do or did you drink?     Y  N   How much_______ How Long?_________When did stop_________

Physician Use only:

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Review of Systems      Pt. Name____________________

Do you now or have you had any problems related to the following systems? Circle Yes or No.

Please explain any Yes answers in space provided
Constitutional Symptom       Skin    
   Fever Y N      Rash Y N
   Chills Y N      Boils Y N
   Headache Y N      Persistent Itch Y N
   Other________________          Other__________________    
Eyes       Musculoskeletal    
   Blurred Vision Y N      Joint Pain Y N
   Double Vision Y N      Neck Pain Y N
   Pain Y N      Back Pain Y N
   Other________________          Other__________________    
Allergic/Immunologic       Ears/Nose/Throat/Mouth    
   Hay Fever Y N      Ear Infections Y N
   Drug Allergies Y N      Sore Throats Y N
   Other_______________          Sinus Problems Y N
Neurological          Other_______________    
   Tremors Y N   Genitourinary    
   Dizzy Spells Y N      Urine Retention Y N
   Numbness/tingling Y N      Painful Urination Y N
   Other_______________          Urinary Frequency Y N
Endocrine          Sexual Dysfunction/ ED Y N
   Excessive thirst Y N      Other_______________    
   Too Hot/Cold Y N   Respiratory    
   Tried/sluggish Y N      Wheezing Y N
   Other_______________          Frequent Cough Y N
Gastrointestinal          Shortness of  Breath Y N
   Abdominal Pain Y N      Other_______________    
   Nausea/Vomiting Y N   Blood/Lymph    
   Indigestion/heartburn Y N      Swollen Glands Y N
   Other_______________          Blood Clotting Problem Y N
Cardiovascular          Other_______________    
   Chest Pain Y N   Psychologic    
   Varicose veins Y N      Are you generally satisfied with life Y N
   High Blood Pressure Y N      Do you feel severely depressed Y N
   Other_______________          Have you considered suicide? Y N

Physician Use Only

 

 

 

 

 

 

 

 

Physician___________________________________Date____________              Pg 7