IMPORTANT – Please fill out all of the below information and read following important disclosures. The whole form is divided into three parts which you should complete:

  • Firstly, the face sheet form where you provide us with your basic information;
  • Second, provide your medical history information to submit these 2 forms;
  • Lastly, we require you to read our HIPAA – Notice of Privacy Practices below. After you have read the notice, download the form, sign it and upload the form before submitting.

After uploading the HIPAA form, you will then be directed to our contact page with a map and directions as well as our contact information.

    FACESHEET FORM

    FACESHEET FORM

    Last Name:*

    First Name:*

    Middle Initial:*

    Address:

    City:

    State:

    Zip Code:

    Social Security Number

    Date of Birth:*

    Age

    Sex

    MaleFemale

    Home Phone Number

    Cell Phone Number

    Email

    Marital Status

    MarriedDivorcedLegally SeparatedWidowedSingle

    Contact Name(Emergency):*

    Contact Phone Number

    Primary Care Physician:

    PCP Number

    Pharmacy Name:

    Pharmacy Location:

    Ethnicity:

    HispanicNon-HispanicNot-Specified

    Race:

    African/African AmericanAsian/Asian AmericanCaucasian/European AmericanNative American/AlaskanNative Hawaiian/Pacific IslanderOther

    The above information is true to the best of my knowledge.
    By sending this form, I agree to the following:

    • I authorize the release of information to my insurance company and any other appropriate agency as required for claims payment.

    • I authorize my insurance benefits to be paid directly to the physician.

    • I understand that I am financially responsible for any balances that are not reimbursed by my insurance company.

    • I agree to inform the staff of St Pete Urology of any changes in my insurance coverage.

    • I agree to pay any deductibles and/or copayments at the time service is provided.

    • If I cancel an appointment within 48 hours of my scheduled appointment or do not show up for a scheduled appointment without any notification, a $25.00 fee will be billed to my account.

    MEDICAL HISTORY FORM

    MEDICAL HISTORY

    Patient Name:*

    Date of Birth:*

    Primary Physician:

    Is this who referred you to us?:

    YesNo

    If not, then who?:

    Other physicians:

    Reasons for coming to this office:

    Have you ever seen a Urologist before?:

    YesNo

    If so, who?:

    Have you ever had any of the following?

    Asthma/Emphysema/COPD: YesNo

    Explain:

    Kidney Stones: YesNo

    Explain:

    Heart disease: YesNo

    Explain:

    Diabetes: YesNo

    Explain:

    Cancer: YesNo

    Explain:

    Hepatitis: YesNo

    Explain:

    Hypertension: YesNo

    Explain:

    Tuberculosis: YesNo

    Explain:

    HIV/Venereal disease/Hepatitis: YesNo

    Explain:

    Low Testosterone: YesNo

    Explain:

    Glaucoma: YesNo

    Explain:

    Parkinson’s disease: YesNo

    Explain:

    Multiple Sclerosis: YesNo

    Explain:

    Stroke: YesNo

    Explain:

    Heart Attack: YesNo

    Explain:

    Do you have any other medical illnesses?:

    List prior operations and approximate dates::

    List ALL medications and doses (including over the counter and herbal supplements):

    Do you have any allergies to medications?:

    YesNo

    If yes, please list?:

    Have you ever had an allergic reaction to contrast dye?:

    YesNo

    Do you take any of the following on a regular basis?

    Coumadin:

    YesNo

    Plavix:

    YesNo

    Aspirin:

    YesNo

    Xarelto:

    YesNo

    Eliquis:

    YesNo

    Ibuprofen/NSAIDS:

    YesNo

    Pradaxa:

    YesNo

    Nitrates:

    YesNo

    Social History:

    Do you smoke?:

    YesNo

    How much do you smoke?:

    Previously smoked?:

    YesNo

    If yes, amount/year quit:

    Do you drink alcohol?:

    YesNo

    How often?:

    Do you have a history of drug use?:

    YesNo

    If yes, explain:

    Do you drink coffee or tea daily?:

    YesNo

    Marital Status:

    SingleMarriedDivorced

    Would you accept a blood transfusion?:

    YesNo

    Family History:

    Does anyone in your family have any of the following?

    Bladder Cancer:

    YesNo

    Who in your family has? Please note if alive or deceased and if deceased indicated age at death.

    Prostate Cancer:

    YesNo

    Who in your family has? Please note if alive or deceased and if deceased indicated age at death.

    Kidney Cancer:

    YesNo

    Who in your family has? Please note if alive or deceased and if deceased indicated age at death.

    Kidney Stones:

    YesNo

    Who in your family has? Please note if alive or deceased and if deceased indicated age at death.

    Kidney Failure:

    YesNo

    Who in your family has? Please note if alive or deceased and if deceased indicated age at death.

    Diabetes:

    YesNo

    Who in your family has? Please note if alive or deceased and if deceased indicated age at death.

    Any other family medical problems?:

    Review of Systems:

    Have you had any recent problems with the following?

    ConstitutionalFatigueNight SweatsUnexplained weight loss

    GenitourinaryBlood in urineBurning urinationErection problemsUrinary frequencyWeak stream

    NeurologicalDizzy SpellsHeadachesNumbness/tingling

    GastrointestinalAbdominal PainBlood in stoolChange in bowel habitsNausea/vomiting

    Cardiovascular/RespiratoryBlood in sputumChest, arm pain with exertionShortness of breathFrequent coughingPalpitations

    SkinRashes

    MusculoskeletalBack PainNeck PainArthritis

    HEENTChange in hearingChange in visionSore Throat

    HematologicBleeding problemEasy bruisingSwollen glands

    EndocrineExcess thirst/hunger

    PsychiatricDepressionAnxiety

    GynecologicHysterectomyAbnormal bleedingBreast cancer



    NOTICE OF PRIVACY PRACTICES

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
    AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

    State and Federal laws require us to maintain the privacy of your health information and to inform you about ouprivacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on April 14, 2003, and will remain in effect until it is amended or replaces by us. It is our right to change our privacy practices provided law permits the changes. Before we make significant change, this Notice will be amended to reflect the changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made. You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, Dr. Robert Spiegel. Information on contacting us can be found at the end of this Notice.

    TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION

    We will keep your health information confidential, using it only for the following purposes:

    Treatment: We may use your health information to provide you with our professional services. We have established “minimum necessary or need to know” standards that limit various staff member’ access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.
    Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.
    Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves some of our office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.
    Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.
    Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our office staff, outside health or management reviewers and individuals performing similar activities.
    Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your
    information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.
    Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.
    Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so.
    National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.
    Appointment Reminders: We may use or disclose your health information to provide you with appointment
    reminders, including, but not limited to, voicemail messages, postcards or letters.

    HIPAA Notice of Privacy Practices
    This form does not constitute legal advice and covers only federal, not state, law.

    YOUR PRIVACY RIGHTS AS OUR PATIENT

    Access: Upon request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be $1.00 for each page. If you want the copies mailed to you, postage and handling fees will also be charged. If you prefer a written summary or explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.
    Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.
    Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care information. (When we make a routine disclosure of your information to a professional for treatment and/or payment purposes, we do not keep record of routine disclosures therefore these are not available.) You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can request non-routine disclosures going back 6 years starting April 14, 2003. Information prior to that date would not have to be released. (Example: If you request information on May 15, 2004, the disclosure period would start on April 14, 2003 up to May 15, 2004. Disclosures prior to April 14, 2003 do not have to be made available.) Please be aware however, that it is the policy of this office not to disclose your health care information to anyone in a “non-routine” manner as defined by the federal privacy law. This section is included in this policy because it is required.
    Restrictions: You have the right to request that we place additional restrictions on our use of disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement. (Except in emergencies.) Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing.

    HIPAA Acknowledgement Form

    Above is the ‘Notice of Privacy Practices’, which states how we may use and/or disclose your health information. Please sign download the form, sign and upload on the form below to acknowledge that you have downloaded the notice.

    QUESTIONS AND COMPLAINTS

    You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us. We may ask you to put your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. However, we hope you will give us the opportunity to address your grievance first.
    Go to our Contact Form for any general questions and/or complaints.

    HOW TO CONTACT US

    St Pete Urology
    830 Central Ave. Suite 100
    St. Petersburg, FL 33701
    727-822-9208
    727-822-9211