Patient Forms

To expedite your appointment and decrease your wait time, we recommend you print and complete the following forms and bring them with you to your appointment.

  • Assignment Of Benefits – This form grants permission for us to bill your medical insurance and for any payment for services to be made directly to us.
  • Patient and Insurance Information – This form provides the necessary information for us to create a medical record for you as well as providing necessary information such as insurance and your other physicians so we can ensure proper coordination of you care and benefits.
  • Health Care Information Disclosure Form-HIPAA – This form serves two purposes; it informs you how we will share your medical information and grants us permission to share your medical information with other specific individuals. We will not be able to share any information to non-designated individuals without your written authorization.
  • Financial Policy Information – We also ask that you please read our Financial Policy for Patient Accounts. This policy will explain the business and financial responsibilities between you and Advanced Urology Institute. Please contact our Business Office at 850-785-8557 if you need additional information or clarification.
  • Your Medication Inventory – Since most people don’t carry around all of their medications, we ask that you complete this medication inventory before you come to your appointment.

Appointment Checklist

Please print the 10 Tips checklist below. Many times, patients leave the office and realize they’ve forgotten to ask a question or didn’t receive or give necessary information. The list below will help you organize your appointment ahead of time.

  • 10 Tips for a Successful Appointment with your Doctor