New Patient Packet

MEDICAL AUTHORIZATION AND LIFETIME PATIENT SIGNATURE

I request that payment of authorized insurance benefits either to me or on my behalf be made payable to UROLOGICAL CONSULTANTS OF FLORIDA, P.A. for any services furnished me by that doctor. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits or the benefits payable for related services. I also understand that if my insurance company does not provide payment to UROLOGICAL CONSULTANTS OF FLORIDA, P.A., I will be billed and agree to pay for said services. I agree to pay for services rendered, including attorney’s fee, collection charges and court cost necessary to effect payment of this account. I also understand that interest charges of 1 ½ % per month may be charged should my account become delinquent.

A photocopy of this authorization shall be considered as effective and valid as the original.

(Your signature is required which will allow us to bill your insurance company.)

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I was given, or offered, a copy of the Notice of Privacy Practices of Urological Consultants of Florida, effective November 15, 2026. The Notice explains how my health information may be used and shared, and describes my rights, including my right to see and get a copy of my records, to ask for corrections, to ask for limits on how my information is used, to be told if my unsecured health information is breached, and to complain without being penalized.

I understand that the practice may change its Notice, and that the current version is available at the front desk and at www.miamiurologyconsultants.com/notice-of-privacy-practices.html.

Signing this form does not mean I agree to anything beyond receiving the Notice. My treatment does not depend on whether I sign it.

Questions about your privacy rights? Ask for our Privacy Officer, Tania Espinoza, at (305) 672-4222.

HIPAA CONSENT FORM

This consent form allows UROLOGICAL CONSULTANTS OF FLORIDA, P.A. to use and disclose information about me protected under the Health Insurance Portability and Accountability Act of 1996. This information may be used or disclosed to carry out treatment, payment or health care operations.

UROLOGICAL CONSULTANTS OF FLORIDA, P.A. has provided me with a Notice of Privacy Practices, which more completely describes such uses and disclosures. It provided this notice prior to my signing this form in accordance with my right to review its practices before signing consent.

I understand that the terms of the Notice of Privacy Practices may change and that I may obtain revised notices by mail or placing the update on our web site.

I understand that I have the right to request, now and in the future, how protected health information is used or disclosed to carry out treatment, payment and health care operations. I understand that UROLOGICAL CONSULTANTS OF FLORIDA, P.A. may refuse me services if I refuse to sign this consent.

I understand that at any time I have the right to revoke this consent provided that I do so in writing, but that the services may still use information to complete any actions that it began prior to revoking consent and which rely on my protected health information.

I understand that UROLOGICAL CONSULTANTS OF FLORIDA, P.A. may refuse me further service if I revoke this consent.