New Patient Registration and Forms

If you are new to our practice, welcome!

The information below is provided to expedite the registration process for new patients. Please read it carefully.

1. You must bring the following items to your first appointment:
   • Your driver's license or other photo ID with a current address. If the photo ID does not show a current address, please bring a utility bill or other correspondence that includes this information.
   • Your current health insurance card
   • A referral from your primary care physician (if needed)

   If the patient is a minor, a parent or guardian must bring the information listed above.

   Please be aware that if the requested information is not presented to our staff at the time of your appointment, we may have to reschedule your visit to allow you to bring the information to the office.

2. Please arrive 15 to 20 minutes prior to your first office visit to allow enough time to complete your registration.

Forms
For your convenience, we have provided several forms to be completed prior to your arrival. You can download and print them out from this website, using the links below. For downloading/printing help, consult PDF Help.

All new patients must complete the following form:

• CMUA Patient Questionnaire (PDF)

In addition to the above forms, please choose the form below that best describes or relates to your medical condition for this office visit.

• Sexual Dysfunction Questionnaire (PDF)
• Incontinence Questionnaire (PDF)

Please print and complete these forms and bring them to your first appointment. If you do not have a way to print them at home, you may request we mail the forms to you by calling our office at 410.772.7000.

Established Patients

"We hope to continue to serve you by providing the best urologic care in a compassionate and understanding manner by accomplished healthcare providers and professional support staff."
- Doctors Kishel, Applestein, Gessler, Rodriguez, Hawes, Nezu, Bepple, and Blumenthal

The information below is provided to expedite the registration process for established patients. Please read it carefully.

It is your responsibility to provide our office staff with all current medical information regarding your health and insurance coverage at the time of your office visit. You will be requested to present:

• Your driver's license or other photo ID with a current address. If the photo ID does not show a current address, please bring a utility bill or other correspondence that includes this information.
• Your current health insurance card
• A referral from your primary care physician (if needed)

Forms
To expedite your visit with us, we have provided several forms you can download and print from this website, using the links below. For downloading/printing help, consult PDF Help.

All established patients must complete the following form if they have not seen a Central Maryland Urology physician in over a year:

• CMUA Patient Questionnaire (PDF)

• Sexual Dysfunction Questionnaire (PDF)
• Incontinence Questionnaire (PDF)
• Male Genitourinary Questionnaire (PDF)
• Female Genitourinary Questionnaire (PDF)

Please print and complete these forms and bring them to your appointment. If you do not have a way to print them at home, you may request we mail the forms to you by calling our office at 410.772.7000.

Prescriptions

In most situations, we are able call in your prescription to a pharmacy. To expedite the process, please have the following information ready to provide to our staff at the time of your call:

• The correct spelling of your name
• Your date of birth
• A telephone number where you can be reached
• The pharmacy name and telephone number
• The name and dose of your medication, as well as how much you receive and how you take it
• If it is a refill, the RX number (usually listed on the label near the top of the bottle) is also helpful.

Please allow us enough time to access your chart, forward it to the doctor, and telephone the pharmacist. In some cases, we may request you call the pharmacist who can then call the doctor directly.

Test Results

Depending on the laboratory and/or the type of test you have performed, it takes anywhere from a few moments to several hours to a couple of days or weeks for our office to receive the results.

Please have the following information available when calling our office for test results:

• The name of the test(s)
• Where the test was performed
• The date the test was performed
• The name of the doctor who ordered the test

Referrals

Many managed-care health insurance plans require patients to obtain a referral before visiting a specialist. Other plans require no referrals. Each plan is different.

Educate yourself about YOUR health insurance plan. Be sure to understand the terms of your coverage and the necessity - or lack thereof - of obtaining referrals and what services are or are not allowed under your plan.

Your insurance carrier has entered into contracts with certain diagnostic centers for services. This may limit your options as to what lab or imaging center you can use. It is important for you to know who participates with your plan.

While we are happy to assist you with your insurance, but we cannot accept responsibility for knowing all of the details of your coverage. Please contact the customer relations department of your carrier to learn more about the details of your health insurance plan. The telephone number is typically listed on your insurance card. Insurance company representatives are far better prepared than our administrative staff to answer questions regarding your health plan coverage.

If you have an insurance that requires a referral, it may be beneficial to request one as soon as you have scheduled your appointment with Central Maryland Urology. Some primary care offices may take up to two weeks to process your request. If you do not have a referral, there is the possibility that you will not be seen by a physician.

Co-Payments

Insurance policy dictates that co-pays be collected at the time of visit. Please check your policy for your co-pay amount and be prepared to pay at the time of service. For your convenience we accept cash, checks, VISA^® and MasterCard^®.

Appointments

Striving to stay "on time" benefits patients as well as physicians. Although office and surgical emergencies may adversely affect schedules and occasionally result in unpredictable waiting periods, we do our best to minimize the impact to patients.

You can help by accurately and completely advising the scheduler why you want to see the doctor when you are making an appointment. The length of your appointment time is based on your candid discussion with that staff member. Arranging an appointment for a routine follow-up and then advising the doctor that a new problem has occurred in the last week while you are in the exam room, may have a negative impact on the schedule for the remainder of the day. Feel free to call and update our staff if you feel you may need more time with the doctor than you had originally planned.

Be sure to arrive with a full bladder 15-20 minutes in advance of your visit. Patients arriving more than 10 minutes late to an appointment may be rescheduled.

There is a $25 charge for missed appointments or visits canceled less then 24 hours in advance.

Your patience and cooperation are greatly appreciated.

Inclement Weather

A decision to close the office is taken very seriously after careful consideration for the safety of our patients and our staff.

We do not follow the local school closings. In the event the office is closed due to bad weather, you will receive a telephone call from one of our staff. If you are unsure of the status of your appointment and have not heard from us, please feel free to contact the office at 410-772-7000. If the office is in fact closed, the answering service will pass along that information to you.

Weigh the necessity of your visit against the risk of the trip. Your well-being comes first, and we will be happy to reschedule your appointment for a later date. If you do plan to venture out, please use extreme caution, especially in the parking lots and sidewalks. If we are open, and you don't call, we can only assume you are planning to keep your appointment.

Holidays

Central Maryland Urology Associates and the Columbia Urological Surgery Center are closed for the following holidays:

• New Year's Day
• Good Friday
• Memorial Day
• Fourth of July
• Labor Day
• Thanksgiving Day and following day
• Christmas Eve and Christmas Day

Quality Assurance

We strive every day to provide the best possible urology care for all of our patients and meeting the needs of other healthcare providers. Sometimes processes in our offices may not meet your expectations. If that is the case, we want to hear from you. Please call 410.772.7000. The practice administrator will assist you with any of your concerns.

Financial Information

To review your financial statement or any other financial matter pertaining to the practice, please call 410-772-7000 and speak with Billing Department personnel.

We accept VISA^®, MasterCard^®, check, or cash for co-payments and office fees.

X-Ray Films

If you have had x-rays taken, please be sure to bring the actual films with you to your appointment. The doctor must see the actual x-ray films and not the image saved to a disc.

Central Maryland Urology Associates, P.A.

Medical Pavilion at Howard County 10710 Charter Drive Suite 130 Columbia, Maryland 21044 [VIEW MAP] Phone: 410.772.7000 Fax: 410.772.7070