Patient Registration - Urology Specialists | Bronx

Manhattan Gramercy Park
201 East 19th Street
New York, NY 10003
Phone: 212-673-7300
Fax: 212-777-0097
Patient Registration
Appointment Date: ________________
Appellido
Primer Nombre
MI
DOB
Throgs Neck
3594 East Tremont Avenue
Bronx, NY 10465
Phone: 718-518-1108
www.aucofny.com
Steven M. Berman, M. D.
Mark Stein, M.D.
Coreo Electronico
__________________________________________________________________________________________________
Direcion
Ciudad
Estado
Codigo Postal
__________________________________________________________________________________________________
Numero de Casa
Numero de Trabajo
Numero de Celular
SS#
__________________________________________________________________________________________________
Sexo
Estado Civil
M o F o Soltero o
Casado o
Divorced o
Viudo/a o Separado/a o
__________________________________________________________________________________________________
Nombre de Emlpeador
Direcion de Empleador
__________________________________________________________________________________________________
Contacto de Emergencia
Relacion
Numero de Casa
Numero de Trabajo Numero de Celular
________________________________ ______________ ________________ ________________
Como Se Le Podemos Dar Las Gracias Por? ______________________________________________________________
El Referido? _______________________________________________________________________________________
Raza
o American Indian or Alaska Native
o Refused to Report / Unreported
Ethicidad
o Hispanic or Latino
o Asian o Black or African American o Native Hawaiian o White
o Other Pacific Islander
o More than one race
o Not Hispanic or Latino
o Refused to Report
Idioma
o English o Spanish o Italian o Russian o Chinese o Korean o Japanese o Other
__________________________________________________________________________________________________
Recides En Un : o Nursing Facility o Rehabilitation Facility o Hospice
Admission Date ___/___/___
Si, Cual Es El Nombre? ____________________________________ Phone (
) _________ – _____________
Address __________________________________________________________________________________
Informacion de Su Doctor Primario
Usual Provider ______________________________ Phone: (212) 673-7300
Fax: ______________________________
Address _________________________________ Ciudad, Estado, Codigo Postal: ________________________________
Doctor de Referencia Direcion ________________________Tel: ___________________ Fax: ___________________
Address _________________________________ Ciudad, Estado, Codigo Postal: ________________________________
Doctor Primario Direcion _____________________ Tel.: ___________________ Fax: _____________________________
Direcion _________________________________ Ciudad, Estado: ____________________________________________
Manhattan Gramercy Park
201 East 19th Street
New York, NY 10003
Phone: 212-673-7300
Fax: 212-777-0097
Patient Registration
Informacion de Seguro Primario
o Medicare
o Medicaid o Health Insurance
o Self Pay
o Worker’s Comp
Throgs Neck
3594 East Tremont Avenue
Bronx, NY 10465
Phone: 718-518-1108
www.aucofny.com
Steven M. Berman, M. D.
Mark Stein, M.D.
o No Fault
Nombre de Aseguardo _____________________________ Nombre de Seguro Direcion ___________________________________
SS de Aseguardo ____________________________________ Seguro Direcion _________________________________________
DOB del Asegurado _________________________ Ciudad Estado, Codigo Postal ________________________________________
Relacion Al Paciente ______________________________________ ID#______________ Group# ___________________________
Secondary Insurance Information
o Medicare
o Medicaid o Health Insurance
o Self Pay
o Worker’s Comp
o No Fault
Nombre de Aseguardo __________________________________ Insurance Name ________________________________________
SS de Aseguardo ____________________________________ Claim Address ___________________________________________
DOB del Asrguardo ______________________________ City, State, Zip _______________________________________________
Relacion Al Paciente ______________________________________ ID#______________ Group# ___________________________
Third Insurance Information
o Medicare
o Medicaid o Health Insurance o Self Pay o Worker’s Comp o No Fault
Nombre de Aseguardo __________________________________ Insurance Name ________________________________________
SS de Aseguardo ____________________________________ Claim Address ___________________________________________
DOB del Asrguardo ______________________________ City, State, Zip _______________________________________________
Relacion Al Paciente ______________________________________ ID#______________ Group# ___________________________
Guarantor Information
Apellido
Primer Nombre
MI
Fecha de Nacimiento Gender M o F o
____________________________________________________________________________________________________________
Direcion
Ciudad
Estado
Codigo Postal
____________________________________________________________________________________________________________
Numero de Casa
Numero de Trabajo
Numero de Celular
SS#
____________________________________________________________________________________________________________
Nombre del Empleador
Direction del Empleador
____________________________________________________________________________________________________________
Relacion al Paciente
____________________________________________________________________________________________________________
Acknowledgement of Financial Responsibility
I hereby authorize Advanced Urology Centers of New York, to release all insurance companies / carriers above any medical or other information required
for processing insurance claims. I certify that I, and / or my dependent(s) have insurance coverage with __________________________ and assign directly
to Advanced Urology Centers of New York, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially
responsible for all charges whether or not paid by insurance.
_______________________________________ ___________________________________________________
Signature of Patient or Authorized Signature
(if over 18 years of age)
Printed Name of Patient or Authorized Signature Date
(if patient is under 18 years of age)
Pharmacy Information
Nombre de Pharmacia _______________________________Tel. _______________________Fax ____________________________
Direcion ___________________________________________ Ciudad Estado ____________________________________________