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Please visit New Website for PDFs of Patient Documents

(Filling these forms out in advance will streamline your visit!)


                                                                                                                                                                             

It is our desire to make your visit to our clinic smooth and efficient. For your convenience, the following forms which pertain to your medical history are availble to you before your visit. Feel free to download and fill out before your visit.  

You may bring the forms with you to your office visit or send them to our mailing address: 660-A Lanier Park Drive Gainesville, GA 30501, or by fax or email. Our fax number is 770-532-3911, and our email address is info@ngurology.com.


Patient Registration
      

Review of Systems
      

New Patient Information


                              

Financial Policy and HIPPA

                   What is HIPPA and why is it important?



Medical information is routinely exchanged between healthcare professionals as deemed necessary by your healthcare provider to assure your safe, continuous care. This information includes records sent to specialists, to emergency departments, hospitals, etc. There is no charge for sending your information to one of these organizations; however, requests for copies of your medical record must be made in writing, must include your original signature, and must be hand-delivered, mailed, or faxed to Northeast Georgia Urological Associates, P.C. You will need to complete the follwoing Medical Record Release Form.  If you are under age 18, your parent or guardian’s signature is required in addition to your own.  Generally, records are copied and mailed within 3-5 business days. 

Medical records mailed to a healthcare provider's office, an individual requesting the record, an attorney's office, insurance company, or a similar company, the charge is $35.00 per medical record .  Files with more than 50 pages will be assessed at 75 cents per page after the 1st 50 pages. This charge must be paid before the record is released. 

                                   

Release of PHI.pdf

The following is a patient satisfaction survey for you to provide us with feedback following your appointment.  Your opinion about our practice, our team and patient service is important to us.  Please download the following survey following your appointment and fax it back to us at 770.532.3911.  You may also email it to info@ngurology.com.  Please feel free to return it by mail or drop it off at the office upon your next visit.  Thank you.

                              

Patient Satisfaction Survey


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