Norman Urology Associates

Patient Information Form

Please complete, print and bring this form to your appointment.

IF SOMEONE OTHER THAN PATIENT IS RESPONSIBLE FOR PAYMENT COMPLETE THIS SECTION

MEDICAL INSURANCE INFORMATION

Asian Native Hawaiian or other Pacific Islander Black or African American White Other
Hispanic or Latin Not Hispanic or Latin Primary Language
AUTHORIZATION
I authorize release of my medical records for insurance claim purposes. This authorization also allows payment directly to physician for medical and/or surgical benefits when necessary. I also understand I am responsible for office charges at the time they incur unless I am covered by an insurance company in which the physician participates. I am responsible for any portion of my bill not covered by my insurance company.