New Patient Forms

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1PATIENT INFORMATION
2Medical History Questionnaire
3HIPAA/ Disclosure of Health Information
4Out side Services for Radiology and Lab

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PATIENT INFORMATION

Marital Status
Name
Marital Status
Address

INSURANCE INFORMATION

If you have given the front desk a copy of your insurance card, then you do not need to fill the insurance portion of this form out.

Is this person is a patient here?
Is this patient covered by insurance?
Please Indicate Primary Insurance
INCASE OF EMERGENCY Contact

Please Read & Sign Below:

I directly assign all Medical/Surgical benefits to Fawad S. Zafar, M.D. & understand that I am financially responsible for all charges whether or not paid by insurance. I understand that payment is due within 30 days of receiving an invoice. I further understand That Lakeview Center for Urology will not check my insurance benefits.

I here by authorize Dr. Zafar to release all information necessary to secure the payments of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

Clear Signature

New Patient Form