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 ____________________________________________