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Authorization to Disclose

Personal Health Information

Welcome to the practice of Dr. Michael Seiba, specializing in all aspects of adult urology. 


Medical Records
In order to improve the efficacy of your initial consultation, it is important for you to provide all your previous relevant medical information. Please bring with you any test results, MRIs, CAT scans, previous surgeries (operative and pathology reports), PSA results, etc. Often times, providers/hospitals who have generated these previous services offer to send our office the information prior to the patient’s appointment, but those documents are rarely received at our office in a timely manner. It is the responsibility of the patient, therefore, to have that information in hand when they arrive at our office. By the same token, updated medical testing records will be needed at subsequent visits as well.


Identification
We ask that patients bring with them, to each appointment, a form of photo identification (preferably a driver’s license) and their insurance card.


New Patient Forms
Additionally, patient demographic forms will need to be completed before patients can be seen for the first time. Patients can either allow themselves extra time before their appointments to complete this paperwork or, more preferably, should bring completed forms to their appointment. 

 

Download "New Patient Form" and "Medication List".
 

No Show Policy
In order for any practice to operate efficiently, it is important for patients to show up on time for their appointments. Patients will receive a reminder call/text a day or two before the scheduled appointment. Those patients who confirm but do not show up will be charged a $30 fee that must be paid before the next visit. Out of respect for our staff and other patients in need of appointments, no show patients will need to wait three months before being rescheduled. Subsequent missed appointments will be grounds for dismissal from the practice.


Procedures/surgeries being performed outside the clinic setting require additional
administrative coordination. As a result, patients who do not show up for these
procedures/surgeries will incur a $100 no show fee for cancelling with less than a 24-hour notice.

   

New Patient Form

Medication List

Designation for Release of

Medical Info to Family

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