Patient Forms

Step 1 of 7 - Patient Information Form

Financial Agreement Form

We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Agreement is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or your financial responsibility.

Patients must fill out patient information forms prior to seeing the doctor. We will request to photocopy your insurance card (s) for your file.
- CO-PAYMENTS – by law, we MUST collect your carrier designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit.
- OUT OF NETWORK PLANS – Since we do not participate with your plan, payment will be expected at the time of service, unless prior arrangements have been made. This includes co-insurance, deductible and non-covered amounts. We will send a courtesy bill to the carrier on your behalf.
Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to OKC Kids Urology, PLLC for any services furnished. I understand that I am financially responsible for any amount not covered by my contract. I also authorize any medical information about me to be released to my insurance company (for their agent) including information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
- SELF PAY PATIENTS – Payment is expected at the time of service unless other financial agreements have been made prior to your visit.
- RETURNED CHECKS – I understand there will be a $25.00 fee for returned checks.
- CANCELLED APPOINTMENTS – I agree and accept the Clinic’s right to charge a $35.00 fee for appointments canceled with less than 24-hour notice or if the patient fails to show up for the scheduled appointment.
- MEDICARE – We will submit claims to Medicare. The patient will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one.
Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits be made on my behalf to OKC Kids Urology, PLLC for any services furnished to me. I authorize any holder of medical information about me to CMS (and it’s agents) to determine these benefits payable for related services. This information will be used for the purpose of evaluating and administering claims of benefits.
- DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS – the guarantor is responsible for payment of services rendered. OKC Kids Urology PLLC cannot be involved with separation or divorce disputes. You are responsible for the timely payment of your account. Our financial staff will work closely with you and your carrier to avoid sending any account to an outside agency to collect payment. We reserve the right to send delinquent accounts to an outside collection agency.
We accept cash, check, Mastercard, Visa. Thank you for taking the time to review our policies. Please feel free to ask questions or share any special concerns with us.
Patient name:
Consent:*
Consent:
I the patient/parent/guardian consent to the above information.
Today's date:
MM slash DD slash YYYY

Email Consent Form
Name of patient:*
First Last
Preferred Email Address:*
Consent*
I consent to the email policy
Hereby consent to have my physician, Dr. Bradley Kropp and/or Jake Klein APRN to communicate with me or members of the staff, where appropriate, other physicians, nurse practitioners, and clinicians via e-mail regarding the following aspects of my medical care and treatment: test results, prescriptions, appointments, billing, etc. I understand that e-mail communications are not a confidential method of communication. I further understand that there is a risk that email communications between my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any e-mail communications between my physician and me or members of this office staff or between my physician and other physicians, nurse practitioners or pharmacists regarding my medical care and treatment will be printed out and made a part of my medical record. I understand that in the urgent or emergent situation, I should call my provider or go to the nearest emergency room and not rely on e-mail.

I have also read the Notice of Privacy Practices.
Name of patient/parent/guardian:
First Last
Date*
MM slash DD slash YYYY

HIPAA 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. PLEASE REVIEW IT CAREFULLY. THIS FORM DOES NOT CONSTITUTE LEGAL ADVICE, AND IT COVERS ONLY FEDERAL, NOT STATE, LAW.

State and Federal laws require us to maintain the privacy of your information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on January 1, 2017 and will remain in effect until it is amended by us.

It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes, and we will make the new Notice available upon request. We reserve the right to make any 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, Gloria Evans. 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 members access to your health information according to their primary job functions. Every staff member is required to sign our 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. Your health information may also be disclosed to your family, friends, and/or other persons you choose to involve in you 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 our business 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 an 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 files, 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 medical records 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, 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 airier 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 healthcare information to report problems with products, reactions to medications, produce 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.

YOUR PRIVACY RIGHTS AS OUR PATIENT

Access: Upon written 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 $25 for the first 20 pages and 15¢ for each page thereafter and the staff time charged will be $75 per hour including the time required to locate and copy your health information. If you want the copies mailed to you, postage will also be charged. If you prefer a summary or an 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 a 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 on January 1, 2017. Information prior to that date would not have to be released.

Restrictions: You have the right to request that we place additional restrictions on our use or 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.

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 in writing. Please request a complaint form from our Privacy Officer. We support your right to the privacy of 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.

HOW TO CONTACT US

Practice Name: OKC Kids Urology, PLLC

Privacy Officer: Laura McKenzie – 405-844-5221 or Tracy Klein – 405-286-0755

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

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Patient Forms

Step 1 of 7 - Patient Information Form

Patient Information Form

General information

Insurance information

Secondary insurance (if applicable)

In case of emergency

Patient History Form

Past medical, family & social history

Pregnancy history for mother of patient:

Social History

Review of systems

Does the patient now or has the patient had any recent problems related to the following systems?

Acknowledgment of Receipt of Notice of Privacy Practices (NPP)

Financial Agreement Form

Email Consent Form

Family Health History

HIPAA Notice of Privacy Practices

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