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What to bring to the appointment Welcome to our practice. We appreciate you choosing us for your urologic care. Enclosed are forms that should be reviewed and filled out before your appointment. They include: 1) Demographic information. 2) History forms and questionnaire. 3) HIPPA privacy policy. In addition, in order to take care of your problem in the most efficient manner, please assist us by obtaining: 1) Any X-rays such as CT, Ultrasound, IVP or MRI on CD-ROM and bring this to our office the day of your appointment along with the written report. 2) If you have a KUB (plain film of the abdomen), please bring the full sized film (not the CD-ROM) to our office the day of your appointment along with the written report. 3) Urinalysis/urine cultures and blood work should be brought in the day of the appointment. 4) Any prior urologic records such as operative reports, pathology reports or previous urologic records should be brought in the day of your appointment. Doing this will assist us in providing the best urologic care possible. Thank you for your assistance in advance. Sincerely, The Staff and Doctors of Urologic Specialists of Northwest Indiana

*Please bring this form completed along with your insurance forms and cards to your appointment. Patient Information Patient Name Last First Middle Home Phone Address Street City State Zip Marital Status Birth Age Sex Race Social Security # Referred by: Employer Phone Address Street City State Zip Email address: Cell# Nearest Relative (Not living with you.) Name Relationship Phone Street City/State/Zip Responsible Party (If other than patient.) Responsible Party _ Last First Middle Home Phone Address Street City State Zip Employer _ Name of Employer Street City/State/Zip Relationship to Patient Phone Social Security # Responsible Party Birth

Insurance Information #1 Company Name Address City/State/Zip Insured Name Policy Number/Group Number/ID Number/Account Number/Benefit Code #2 Company Name Address City/State/Zip Authorization To Pay Benefits To Provider I, authorize and request that payment under my insurance program (Medicare, Blue Shield or any commercial insurance carrier-basic or Major Medical) be made payable to Urologic Specialists of Northwest Indiana for any service rendered to me during the period of. I also authorize the release of any medical information necessary to process a claim on my behalf and a copy of this authorization to be used in place of original. I understand that I am financially responsible to the provider physician for charges not covered by my policy. X Signature (Insured/Legal Guardian) I have read the Urologic Specialists of Northwest Indiana Statement of Financial Policy. I understand and agree to this policy. X Signature of Patient or Responsible Party

Please complete the below information if on Medicare STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDER PHYSICIANS AND PATIENTS I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished me by or in Urologic Specialists of Northwest Indiana, including physician services. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or benefits for related services. X Signature I request that payment of authorized MediGap benefits be made either to me or on my behalf to Urologic Specialists of Northwest Indiana, for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to release to (Medigap Insurer) any information needed to determine these benefits or any benefits payable for related services. X Signature

Female History Form Last Name: First: Middle: Today s : of Birth: Referring Physician: CHIEF COMPLAINT: (Reason for visit today) List Any Allergies Dye Y N Latex Y N Iodine Y N Shell Fish Y N Medication Allergies: Medications (Currently Taking) Name Amount Times/Day List Any Past Surgeries Type (Year only) Patient s Medical History When Diagnosed (Year) Cancer Y N Type Diabetes Y N Emphysema Y N Heart attack Y N Heart failure Y N Hypertension Y N Kidney stones Y N Other _ Pregnancy Y N Number of children Vaginal delivery C-section Menses: every days Regular Irregular

Social History Occupation: Do You Smoke? Y N How Much? Do You Drink Alcohol? Y N How Much? Family History Family Member Cancer (type) Y N Diabetes Y N Heart disease Y N Kidney stones Y N Stroke Y N Review of Systems Do you now or have you had any problems related to the following systems? Circle Yes or No. Constitutional Symptoms Fever Y N Chills Y N Headache Y N Eyes Blurred vision Y N Double vision Y N Pain Y N Allergic/Immunologic Hay fever Y N Drug allergies Y N Neurologic Tremors Y N Dizzy spells Y N Numbness/tingling Y N Ear/Nose/Throat/Mouth Ear infection Y N Sore throat Y N Sinus problem Y N Gastrointestinal Abdominal pain Y N Nausea/Vomiting Y N Heartburn Y N Cardiovascular Chest pain Y N Varicose veins Y N High blood pressure Y N Integumentary Skin rash Y N Persistant itch Y N Musculoskeletal Joint pain Y N Neck pain Y N Back pain Y N Genitourinary Painful urination Y N Bloody urine Y N Urinary retention Y N Respiratory Wheezing Y N Frequent cough Y N Shortness of Breat Y N Hematologic/Lymphatic Swollen glands Y N Blood clotting prob. Y N Psychological Feel depressed Y N Endocrine Excessive thirst Y N Too hot/cold Y N Tired/sluggish Y N

1. On average, how many times a day do you urinate? 2. On average, how many times a night do you urinate? 3. During a typical day, how many protective pads do you wear? diapers maxi pads panty liners 4. Do you leak urine at night in bed? Yes No 5. How often do you have such a strong urge to urinate that you expect leakage before you reach the toilet? often sometimes seldom never 6. How often do you leak urine when you sneeze, cough, laugh or exercise? often sometimes seldom never 7. Which causes most of your leakage? above #5 above #6 8. Do you have to strain to get a urine stream started? Yes No 9. Do you feel like you empty your bladder? Yes No 10. Have you ever had bladder or kidney infections? Yes No 11. How often do you experience pain or discomfort when you urinate? often sometimes seldom never 12. Have you ever had surgery to correct urinary incontinence? Yes No 13. How long have you had urinary incontinence? Years Months Physician

Statement of Financial Policy Thank you for choosing Urologic Specialists of Northwest Indiana as your health care provider. We are committed to the success of your treatment and care. Please understand that payment for service is part of this process. The following is our Statement of Financial Policy, which we request all of our patients to read, understand, and sign prior to any treatment or care. When Is Payment Due? Payment is due at the time services are rendered in the office. To see how this affects your specific insurance situation, please read the About Your Insurance Coverage section of this policy thoroughly. Methods of Payment We accept cash, checks, VISA and MasterCard. We offer payment plans and are happy to provide financial counseling if necessary. Please ask for the Practice Manager if you wish to discuss alternate payment methods. About The Fees We Charge You may notice information on your Explanation of Benefits forms that relate to usual and customary fees. You should understand that Urologic Specialists of Northwest Indiana fees are in-line with other physician groups in the area. We have completed a full analysis of our fee schedule using the McGraw-Hill Relative Values for Physicians. This is an industry-standard tool to determine fees and is used by Blue Cross Blue Shield plans in at least 16 states, as well as hundreds of other insurance companies and managed care plans, In addition, we have compared our fees to payments by managed care plans and insurance companies in NW Indiana and feel confident our charges are appropriate. Patients Who Are Minors The adult accompanying a minor and the parents (or guardians) are responsible for payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, VISA/MasterCard, or payment is made by cash or check at the time of service. About Your Insurance Coverage The amount that is due at the time of service may vary, according to your insurance policy. Please note the following guidelines: Commercial insurance- also known as indemnity insurance, or 80%/20% coverage.

If you have commercial insurance, you will be asked to pay your entire balance at the time services are rendered in the office. We will then file your insurance claim for you, and the insurance company will mail the reimbursement check directly to you. Please note that your commercial policy is a contract between you and the insurance company. Because we are not part of that contract, your account balance is your responsibility whether the insurance company pays or not. Managed care plan- also known as an HMO, PPO, POS or EPO. If we participate with your plan, we will accept the appropriate co-pay as payment in full at the time of service. You will not be asked to pay the full charge. We will then file your insurance claim for you. In the case of some PPOs and POS plans, we may later send you a statement for the amount, which is your responsibility, according to the terms of your policy. Please be aware that some services may not be a covered benefit under your managed care plan. In that case, all non-covered services are your responsibility to pay in full the day services are provided. Medicare Urologic Specialists of Northwest Indiana participates in the Medicare program. This means we accept payment of the Medicare allowable as payment in full Medicare pays 80% of this allowable, and beneficiary is responsible for the remaining 20%. Medicare patients will be asked to pay their deductible at the time of their visit, if it is not yet paid. Once it has been met, the following policy applies to our Medicare patients. If Medicare is your primary insurance, and you also have secondary coverage, we will file your claims for you. No payment is necessary at the time of service. Medicare will automatically transfer 20% to your secondary insurer, and send payment directly to our office. If Medicare is your primary insurance, and you do not have secondary coverage, we will ask that the 20% copay be paid at the time of service. Our staff has already calculated these amounts, and will inform you about your responsibility. Medicaid If you are a Medicaid patient, we will file your claim for you. You will not be asked to pay at the time of service. Uninsured If you do not have insurance coverage, payment in full is requested at the time of service. If you are unable to pay for your service in full, please ask to speak with our practice manager to discuss financial arrangements. Please Remember: In order for us to successfully bill your insurance company, we need complete information. Please cooperate with our Reception Services staff in providing this information. Although our staff understands multiple insurance company guidelines, they do not have all the answers. Please contact your employer for a copy of your Benefit Guidebook, should you need detailed information about your coverage. Thank you for reviewing our Statement of Financial Policy. Let our practice manager or billing team know if you have any questions or concerns.

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