What to Bring to Your Appointment

• Your insurance card

• Physician referral forms, if required by insurance

• List of prescriptions and/or over-the-counter medication, including dose and frequency, and start date

• Information about your medical and surgical history

• Recent x-rays or relevant records

• Appropriate completed patient forms

Patient Forms

We are pleased to offer you the opportunity to print our forms, information sheets, and patient instructions at your convenience from this website.

[click here for information on accessing and printing forms]

• Patient registration form
• Patient history form (adult)
• Patient history form (pediatric)
• Fertility questionnaire
• Incontinence questionnaire
• International index of erectile function questionnaire
• Medication list
• Prostate health symptom score (BPH)
• Notice of Privacy Practices for Protected Health Information
• Acknowledgment form for Notice of Privacy Practices

Insurance and Payment Information

Southwest Urologic Specialists, PC, is a provider for Medicare and most major insurance plans. As a courtesy, we will file your insurance claim for you. We want to help you receive reimbursements from your insurance company. Patients should confirm our participation status with their insurance company or managed care plans.

Copayments and 'patient responsibility' are collected at the time of your appointment. Statements are sent out monthly. If you are not able to pay your bill within 10 days of receipt, please call our office at 480.897.2727 ext 8 to make arrangements.

Please contact 480.897.2727, extension 8 for any questions or problems about your insurance billing/reimbursement. Again, if you would like assistance, please contact us.

Emergencies

In case of emergency, call our office at 480.897.2727. Our phone is answered from 8:00 a.m. to 4:30 p.m. Monday through Thursday and 8:00 a.m to 12:00 p.m. on Friday.

Office-hour emergencies: You will be able to speak with a clinical staff person who will give you instructions. It is important to call the office prior to going to the emergency room. The call could save you time and help you get quicker service.

After-hour emergencies: The answering machine will give you instructions on how to contact the physician on call.

Confidential Patient Information

All new patients are asked to complete an information sheet. Please notify us of any address, phone number, or insurance changes. Remember the information in your chart is confidential and the entire staff will respect and protect that confidentiality.

Releasing Medical Records

If you wish to have your records released to an insurance company or another physician, you will be required to sign an authorization to release medical information.

Medical Facility Affiliations

Southwest Urologic Specialists, PC, holds privileges at the following medical facilities:

• Banner Baywood Medical Center
• Banner Gateway Medical Center
• Surgery Center of Gilbert

Southwest Urologic Specialists, PC
875 N. Greenfield
Suite 105
Gilbert, AZ 85234
Tel: 480.897.2727
Fax: 480.892.3035
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