Get La West Jefferson Urology Specialists New Patient Information 2015-2025

Completing the LA West Jefferson Urology Specialists New Patient Information form online is an important step in your healthcare journey. This guide will provide you with clear instructions to help you navigate each section of the form, ensuring that you submit accurate and complete information.

Follow the steps to accurately fill out your patient information form.

1. Click the ‘Get Form’ button to obtain the form and open it in a suitable editor.
2. Provide your primary care physician's name, and if applicable, the name of the referring doctor. This information helps the specialists understand your healthcare background.
3. Enter your personal details, including your full name, address, city, state, and zip code. Ensure that all information is spelled correctly to avoid any issues with communication.
4. Fill in your home and cell phone numbers. These will be used to contact you regarding your appointment and healthcare needs.
5. Input your date of birth and age. This information is vital for patient identification and care.
6. Provide your social security number. This is often required for insurance and identification purposes.
7. Select your preferred language and marital status. These preferences help the office accommodate your needs.
8. Indicate your race by circling one of the provided options. This information may be used for demographic purposes.
9. Specify your sex by circling the appropriate option.
10. List an emergency contact and their phone number. Ensure that the person you list is aware that they are your emergency contact.
11. Provide information about your employer and work phone number. If you are a student, share the name of your school and whether you are attending full-time or part-time.
12. Complete the section for insurance information. Enter your primary and secondary insurance details, including the group number, member ID, and policy holder information. If the policy holder is not yourself, provide their name, date of birth, and employer.
13. Review the information you have entered for accuracy and completeness. This step is crucial to avoid any delays in processing your new patient information.
14. Once all sections are filled out, save your changes, and you can then download, print, or share the form as needed.

Complete your new patient information online today to ensure a smooth appointment process.