Valley Urology
6113 N. Fresno St.
Suite #101
Fresno, CA 93710
Ph (559) 438-2777
Fax (559) 438-4117

Please call for an Appointment
For new patients, please download and fill-out by hand the blank PDF patient forms, or type and then print them out using the online template
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PATIENT REGISTRATION
PATIENT INFORMATION :
Patient :
Home Phone : Daytime Phone : CellPhone :
Street Address :
City : State : Zip :
Sex : M F  Age :   Birth Date : Sg. Mr. Wd. Sp. Div.
Social Security: Driver's License:
Patient Employed By : Business Phone :
Referring Physician : Primary Physician :
 
SPOUSE/RESPONSIBLE PARTY INFORMATION :
Resposible Party (If patient is a minor) :
Relationship to Patient :
Street Address :
City : State : Zip :
Social Security: Driver's License: Birth date :
Employer : Occupation :
Business Address : Day/Business phone :
Spouse: Social Security:
Driver's License: Birth date :
Employed By : Occupation :
Business Address : Day/Business phone :

In case of Emergency (Relative or Friend) :

Relationship : Telephone :

 
CONSENT
I hereby give consent to release or obtain information to/from physicians and other medical personnel, as may be required in the rendering of treatment. I understand that I am financially responsible to the above named office for the services rendered. In the event of collection action, I shall be responsible for any legal fees incurred. This authorization expires one (1) year from the date of signature.
 

Patient Responsible Party Signature :

  Date :
ASSIGNMENT
I hereby authorize payment directly to the attending physician of any medical/surgical benefits payable to me under the conditions of my policy for services rendered. I hereby give consent for release to authorized person of financial and medical information concerning care, treatment and charges as may be required to complete all claims for benefits.
 

Patient Responsible Party Signature :

  Date :
 
INSURANCE INFORMATION
Name of Primary Insurer :
Address :
Policy : Group : Subscriber :
Name of Secondary Insurer (if any) :
Address :
Policy : Group : Subscriber :
 
MEDICARE/MEDI-CAL INFORMATION
Medicare Medical Claim ID :
Medicare Secondary Payer Information :
Are you covered by a medical insurance plan where you work? Yes No
Are you covered by a medical insurance plan from your spouse’s employer: Yes No
Do you have any medical insurance, other than medicare ? Yes No
Is that Medicare supplemental insurance ? Yes No
    
 
 
6113 N. Fresno St. Suite #101 Fresno, CA 93710 Ph: (559)438-2777, Fax: (559)438-4117 www.ValleyUrology.com