New Patient Forms

Use the following links to download forms that may be necessary for your appointment. Please call if you need clarification about which forms are needed. For the ones you need to fill out, please print a copy and complete the form. Please bring all completed forms to your appointment.
[PDF/printable page help]

• New Patient Registration Form [PDF]
• New Patient Medical History Form [PDF]
• Authorizations Form [PDF]
• Notice of Privacy Practices (For your information only)
• Acknowledgement of Receipt of Notice of Privacy Practices [PDF]
• Authorization To Disclose Personal Health Information [PDF]

Vasectomy Forms and Info

Use the following links to download forms and information related to vasectomy appointments. Please bring completed forms to your appointment.
[PDF/printable page help]

• Answering Your Questions About Vasectomy [PDF]
• Vasectomy Forms (Medical Form and Patient Instructions) [PDF]

What to Bring to Your Appointment

• Your insurance card
• Physician referral forms, if required by insurance
• List of prescriptions and/or over-the-counter medication, including dose and frequency
• Information about your medical and surgical history
• Recent x-rays or relevant records

Insurance and Payment Information

Urology Specialists, P.A., is a provider for Medicare and most major insurance plans, and provides insurance billing. You are responsible for charges that are not covered by your insurance, at the time of your appointment.

Your insurance company may require a co-payment at the time of your appointment. When necessary, our staff will work with patients to set up a payment plan.

If you have questions regarding billing or which insurance plans we accept, please call us at the phone number below. Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.