Download Authorization of Treatment / Assignment of Benefits Form GENERAL

LVPG Urology - 1250 Cedar Crest
1250 S Cedar Crest Blvd, Suite 215
Allentown, PA 18103
(P) 610-402-6986 (F) 610-402-4460
We would like to thank you for choosing
LVPG Urology – 1250 Cedar Crest.
Please complete all attached forms before your first appointment. In order to provide you with the
most complete and comprehensive evaluation on the day of your visit, it is very important that we
have your complete medical information regarding your past and present health.
If you have had any of the following tests we will need to have the images put
on a disc before your appointment. All ultrasounds, X-rays, CT scans, MRIs or a
previous NOT performed at:
Lehigh Valley Hospital
Lehigh Valley Diagnostic Imaging
Lehigh Magnetic Imaging Center
**YOU MAY BE ASKED TO PROVIDE A URINE SAMPLE**
Please bring your insurance card(s), photo identification AND prescription card with you on the
day of your visit. If your insurance requires that you have a referral, please request this from
your primary care physician as soon as possible and have it faxed to our office prior to your
appointment.
If you need to cancel or reschedule for any reason, please call at least 24 hours in advance. Do not
hesitate to call our office if you have any questions or concerns. We look forward to meeting you
in the near future.
If this visit is for a vasectomy consult please call the number on the back of your card to see if this
consult and the procedure itself is a covered service. If this procedure is not a covered service the
patient will be responsible for the cost of the consult/procedure.
Thank you from all of us here at LVPG Urology!
Updated 04/08/2015
LVPG Urology - 1250 Cedar Crest
1250 S Cedar Crest Blvd, Suite 215
Allentown, PA 18103
(P) 610-402-6986 (F) 610-402-4460
Patient Information
Name: ____________________________________________________________
Nickname: __________________________
Sex: M / F
Date of Birth: __________________
Social Security: ____________________________
Street Address: ___________________________________________________________________________________________________
Street, PO Box
City
State
Zip
Contact Phone Numbers (home, work, cell):
Employer:
Primary: ________________________________ (H/W/C)
Company Name: _______________________________________
Secondary: ______________________________ (H/W/C)
Address: ______________________________________________
Alternate: _______________________________ (H/W/C)
______________________________________________
E-Mail Address: __________________________________________ Status(circle one): Full-time / Part-time / Retired / Not employed
Additional Information
Preferred Spoken Language: ________________________
Race: ____________________/ Decline
Preferred Written Language: _____________________
Ethnicity: Hispanic / Non-Hispanic / Refused
Religion: _____________________ / Decline
Veteran: Y / N
Marital Status: M / S / D / W
Branch: ____________________
Pharmacy Name and Address: ______________________________________________________________________________
Referring Physician Name: ____________________________________/ Self
Referring Physician Phone #: ______________________
Primary Care Physician Name: _________________________________/ None
Primary Physician Phone #: _______________________
Emergency Contact
Emergency Contact: ___________________________________ Relationship to you: ________________Contact #: __________________
Insurance Information
Primary Insurance Company: ____________________________________________
Referrals Required: Y / N
Primary Insured Name: _____________________________________ Insured Relationship to Patient: _______________
(Are you the policy holder or is your spouse/parent?)
(Parent, Legal Guardian, Spouse)
Insured Date of Birth: _______________
Insured Social Security Number: _______________________
Secondary Insurance Company: __________________________________________
Referrals Required: Y / N
Primary Insured Name: _____________________________________ Insured Relationship to Patient: _______________
(Are you the policy holder or is your spouse/parent?)
(Parent, Legal Guardian, Spouse)
Insured Date of Birth: _______________
Insured Social Security Number: _______________________
Patient/Guardian Signature: ____________________________________________
Updated 04/08/2015
Date: _______________
LVPG Medical Information Communication Preferences
As our patient, we may need to communicate with you when you are not in the practice. To maintain your privacy,
please indicate your preferred method for us to communicate confidential medical information, such as test or lab
results, to you and/or others involved in your care. Please note that “appointment reminder telephone calls” may
be left at the contact number(s) you list below.
PLEASE INDICATE YOUR COMMUNICATION PREFERENCES BELOW:
 I give permission to leave medical information pertaining to me, my dependent or child, at the
numbers listed below:
Method
Yes
No
Area Code, Phone #, Ext, E-mail
Home telephone
Answering Machine
Work Phone
Cell Phone
Secure E-mail (Patient Portal secure
email registration only)
Pager
Without specific permission, we will not release any medical information to anyone other than you. In some
cases you may wish for another person to have access to your medical information. Please identify those
individuals and their relationship to you (i.e. spouse, parent, son, daughter, partner etc.):


Do not release medical information to anyone other than myself.
I give permission to release medical information pertaining to me to the individuals listed below.
Name
Relationship (i.e. spouse, parent, son,
daughter, etc.)
Area Code, Phone # - Extension
Comments
I assume responsibility to inform the practice of changes in my phone number(s) or my preferences or to revoke
this specific medical information authorization at any time.
___________________________________________________
______________________
Signature of Patient or Patient’s Legal Representative
Date
___________________________________________________(Please Print Signer’s Name)
Updated 04/08/2015
Medical History Questionnaire
Name: ________________________________ MRN: ________________________
Do you have an advance directive?
□ Yes
Are you a victim of violence or abuse? □ Yes
Had a flu shot this year?
□ Yes
Had a pneumonia shot?
□ Yes
□ No
□ No
□ No
□ No
Describe briefly in your own words, the major medical problem or need that brings you to see
our physicians, and when the problem began?
Medical History
Please list any medical problems you have; add any details that might be helpful.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Surgery
Surgical History
Please list any surgeries you have had.
Reason
Hospital / State
Year
Medications/Dosages
Please list medications and supplements you take.
Instead of writing your medications you may bring a list of them with you to your
appointment.
Medication
Dose
Medication
Dose
Medication
Dose
Allergies
Please list any medications, foods, or other substance to which you have had an allergic reaction
to.
Medication / Other
Reaction
Updated 04/08/2015
Social History
Are you sexually active? □ Yes □ No □ Not currently
Partner: □ Male □ Female
Current method/form of birth control? __________________________ □Not Applicable
How many children do you have? ____________
Are you currently employed outside the home? □ Yes □ No
Are you retired? □ Yes □ No
Have you ever smoked? □ Yes □ No
If yes, number per day ______
How many years did you smoke? ______
Have you quit? □ Yes □ No
7. Do you drink alcoholic beverages? □ Yes □ No
Amount per day/week? _____
8. If you previously drank heavily, how much, when did you quit? ______________
9. Do you use illegal substances or drugs? □ Yes □ No
If yes, which one(s)? __________________________
1.
2.
3.
4.
5.
6.
Family History
List any relatives who have or previously had cancer, indicate the location of cancer or tumor,
and how the individual was related to you.
Relative
Location of cancer / tumor
MALE ONLY
TESTOSTERONE SCORE
1.  Do you have a decrease in libido (sex drive)?
2.  Do you have a lack of energy?
3.  Do you have a decrease in strength and/or endurance?
4.  Have you lost height?
5.  Have you noticed a decreased enjoyment in life?
6.  Are you sad and/or grumpy?
7.  Are your erections less strong?
8.  Have you noted a recent deterioration in your ability to play sports?
9.  Are you falling asleep soon after dinner?
10.  Has there been a recent deterioration in your work performance?
WOMEN ONLY
1.
2.
3.
4.
5.
6.
7.
How many times have you been pregnant? _______
How many times have you delivered a baby? _______
How old were you when you delivered your first baby? ______
When was your last PAP smear? _______
When was your first menstrual period? _______
When was your last menstrual period? _______
Had you previously had a breast biopsy? _______
If so, when and where? ______________________________________________
8. Have you gone through menopause? Y / N
9. Do you do self-breast examinations? Y / N
How frequently? ____________________________
10. Have you used hormone replacement therapy? Y / N
If yes, what type _____________________________________________________
How long? __________________________________________________________
Updated 04/08/2015
Age of diagnosis