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Cynthia J. Moorman M.D., P.A.

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Cynthia J. Moorman M.D., P.A.
PATIENT INFORMATION
Last Name: First Name: MI:
Gender: Date of Birth: Social Security #:
Race: Ethnicity (check one): Hispanic or Latino Other
Street Address:
City: State: Zip Code:
Home Phone #: Cell Phone #:
Work Phone #: Preferred Contact Phone #: Work Home Cell
Employment Status: Full-Time Part-Time Retired Not Employed Self Employed Military Duty
Email Address: Marital Status:
Employer: Occupation:
Referring Doctor: Primary Doctor:
Student Status: Full-Time Part-Time Not a Student
EMERGENCY CONTACT INFORMATION
Last Name: First Name: MI:
Relationship to Patient: Home Phone #
Cell Phone #: Work Phone #:
GUARANTOR INFORMATION
Last Name: First Name: MI:
Gender: Date of Birth: Social Security #:
Street Address:
City: State: Zip Code:
Home Phone #: Cell Phone #:
Work Phone #:
Relationship to Patient: Self Spouse Child Other: ________________________
Cynthia J. Moorman M.D., P.A.
INSURANCE INFORMATION
1
st
Insurance: 2
nd
Insurance:
Policy/Member #: Policy/Member #:
Group #: Group #:
Policy Effective Date: Policy Effective Date:
Subscriber Name: Subscriber Name:
Home Address: Home Address:
City/State/Zip: City/State/Zip:
Subscriber Date of Birth: Subscriber Date of Birth:
Subscriber SSN #: Subscriber SSN #:
Relationship: Self Spouse Child Other Relationship: Self Spouse Child Other
Employer Name: Employer Name:
Retired: Yes No Retired: Yes No
I authorize Cynthia J. Moorman, MD, PA to apply for benefits on my behalf for services rendered by Cynthia J.
Moorman, MD. I request payment from my insurance company be made directly to Cynthia J. Moorman, MD, PA I
certify that the information I have reported with regard to my insurance coverage is correct and further authorize
the release of any necessary information, including medical information for this or any related claims. I permit a
copy of the authorization to be used in place of the original. I may revoke this authorization at any time in writing. I
understand that nothing herein relieves me of the primary responsibility and obligation to pay for medical services
provided, when a statement is rendered.
Signature of Patient or Responsible Party Date Rev. 06/30/2018
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Cynthia J. Moorman, M.D., P.A.
PATIENT HISTORY FORM
Name: Date of Birth: Age:
Appointment Date: Height: Weight:
Race: Ethnicity (check one): Histpanic or Latino Other
Primary Language: English Other Primary Doctor:
Reason for your visit:
Most frequently used local pharmacy:
Medical History:
List any Surgeries you have had:
Current Medications you are taking including over-the-counter, vitamins, & supplements
include dosage and reason:
Medication Allergies/Reaction:
Latex Allergy: Choose Yes No Choose One: Airborne Contact
Family History: Is there any urologic disease(s) in your family? Yes No
If yes, please explain:
First Degree Relative (Mother, Father, Sister or Brother) with history of: Cancer, Heart Disease,
Diabetes or High Blood Pressure? If Yes, List relative and Disease:
Social History: Do you smoke? Yes No If yes, how many packs per day?
Have you ever smoked? Yes No Chew tobacco? Yes No
OB/GYN History (For Women Only): Last Mentrual Cycle:
Number of Births: Vaginal or C-Section: Hysterectomy: Yes No
REVIEW OF SYSTEMS Check () For Current Problems
Wheezing Mumps
Urination – Overactive Bladder
Shortness of breath AIDS Overnight more than twice
Chest Pain Sexually transmitted diseases More than 8 times/ 24 hours
Abdominal Pain Sexual problems Urgency to urinate with leakage
Gallbladder trouble Alcohol_____ oz per week Decrease in force/flow
Fever Chills Street drugs Painful urination
Diarrhea Coffee/Tea _____ cup per day Stress incontinence – urine leakage
Weight lost/gain Exercise with exercise/movement
Change in appetite Blood in urine
Blood transfusions Kidney stones
Easily fatigued Urinary infections - frequent
Headaches – frequent
FEMALES – Please complete
Numbness / tingling sensations menstrual flow: Regular Irregular Pain / Cramps
Sleep problems Pain / Bleeding during or after sex
Back Pain – Recurrent Flushing / Menopause
Depression
Nervousness
Memory Loss
If over 65, Do you have an Advanced Directive? If so please bring a copy to appointment.
Have you had Flu Vaccine? If yes when?
Pneumonia Vaccine? If yes When?
Last Tetanus Shot:
Patient or Guardian Signature Date Form Date 06/30/2018
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Cynthia J. Moorman, M.D., P.A.
FINANCIAL POLICY
Patient Name: Date of Birth:
We are committed to providing our patients with the best possible medical care. This policy has been
established to avoid any misunderstanding or disagreement concerning payment for profession services.
It is your responsibility to:
• Bring your insurance card(s) at every visit.
• Be prepared to pay your Deductible, Coinsurance, and/or Copay at each visit. Payment can be
made by cask, check or credit card. We accept Visa and MasterCard. There will be a $25.00
charge for all returned checks.
• Bring any required insurance referrals for treatment at the time of your appointment. If you
do not have the referral, your appointment may be rescheduled, or you will be financially
responsible for all charges incurred.
• Non-participating insurances: If we do not participate with your insurance, you will be
responsible for payment in full at the time of each visit. We will file a claim to your insurance
company as a courtesy. Your claim will process at your out-of-network benefit level.
• Patients with no medical insurance coverage: If you have no active medical insurance coverage,
you will be expected to pay for services in full at the time of each visit.
• It is ultimately your responsibility to know your individual coverage limitation. If you have
questions about your insurance, we are happy to help you. However, specific coverage issues
should be directed to your insurance company member service department.
• Please give the office 24 hours notice if you are unable to keep your appointment. A $40.00
fee may be charged for missed appointment without 24 hour notification. Patients missing
appointments that require a sign language interpreting service will also be responsible for the
service charge of the interpreter. Please help us serve you and all of our patients better by
keeping scheduled appointments.
• Completing insurance forms, medical leave, disability forms, copying of medical records, etc.
requires office staff time and time away from patient care for our doctor. We require pre-
payment for these services which are determined by the length and complexity of the form or
letter and the prep and the number of pages copied of the medical record.
• If your account is placed in the hands of collection agency and/or attorney for collection, you
will be responsible to pay for any unpaid balance and all collection and/or attorney fees.
• If the patient is a minor (18 years and younger), the parent or guardian must sign below. The
parent, guardian, or unaccompanied minor is responsible for all above mentioned charges.
Questions about financial arrangements should be directed to the physician’s office. We are
here to help you. Please sign that you have read and agree to this Financial Policy
Signature of Patient (or Responsible Party, if Minor) Date Form Date 06/30/2018
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Form Date 6/30/2018
Cynthia J. Moorman, M.D., P.A.
DISCLOSURE OF HEALTH INFORMATION
Patient Name: Date of Birth:
By signing this form, you are granting consent to Cynthia J. Moorman, M.D., P.A. to use
and disclose your protected health information for the purpose of diagnosis or providing
treatment to you, obtaining payment for your health care bills, or to conduct health care
operations. Our Notice of Privacy Practices provides more detailed information about how we
may use and disclose your protected health information notice is available in our office at the
front desk. You have the right to review our Notice of Privacy Practices before you sign this
consent.
Your “protected health information” is information about you, including demographic
information, that identifies you and relates to your past, present, or future physical or mental
health condition.
You have the right to request a restriction as to how we use and disclose your health
information for the purposes of treatment, payment, or health care operations. We are not
required by law to grant your request. However, if we do decide to grant your request, we are
bound by our agreement.
You have the right to revoke this consent in writing, except to the extent that we have
already used or disclosed your health information in reliance on your consent.
Cynthia J. Moorman, M.D., P.A. reserves the right to revise the Notice of Privacy
Practices. The revised notice will be maintained in our office. You may request a copy by calling
our office or at the time of your next appointment.
I, _________ hereby authorize Cynthia J. Moorman, M.D., P.A. to disclose/discuss my
medical information to the following individuals:
Name Relationship
Name Relationship
Signature of Patient or Responsible Party Date
Relationship to Patient
Form Date 06/30/2018
Cynthia J. Moorman, M.D., P.A.
77 Thomas Johnson Drive, Suite K
Frederick, MD 21702
Phone: (301) 662-4868 Fax: (301) 662-0050
NOTICE TO PATIENTS
DISCLOSURE OF PHYSICIAN OWNERSHIP
Please carefully review the information contained in this notice.
1. Cynthia J. Moorman, M.D., is an owner of Thomas Johnson Surgery Center, LLC.
2. You have the right to choose the provider of your health care services. Therefore, you have
the option to use a health care facility other than Thomas Johnson Surgery Center, LLC.
3. You will not be treated differently by your physician if you choose to obtain health care
services at a facility other than Thomas Johnson Surgery Center, LLC.
If you have any questions concerning this notice, please feel free to ask your physician or any
representative of Thomas Johnson Surgery Center, LLC. We welcome you as patient and value
our relationship with you.
By signing this Disclosure of Physician Ownership, you acknowledge that you have read and
understand the foregoing notice and hereby understand that your physician has an ownership
interest in Thomas Johnson Surgery Center, LLC.
Patient Name: Date of Birth:
Signature of Patient Date
Signature of Parent or Guardian (if applicable)
Print Name of Parent or Guardian (if applicable)
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Cynthia J. Moorman, M.D., P.A.
77 Thomas Johnson Drive, Suite K, Frederick, MD 21702
Phone: (301) 662-4868 Fax: (301) 662-0050
NON-CONTRACTED INSURANCE POLICY
Patient Name: Date of Birth:
Dr. Moorman does not want to turn away care based on insurance coverage therefore; we
must inform you of the following:
• It is ultimately your responsibility to know your individual insurance coverage limitations.
• If Cynthia J. Moorman, MD is not a contracted provider with your insurance carrier, you will
be responsible for 100% of the charges incurred.
• We require a $100.00 per date-of-service deposit if we are not a participating provider with
your insurance and you will receive a bill for the remaining balance.
• Our billing staff will file a claim on your behalf as a courtesy.
• Your claim will process at the out-of-network benefit level.
• Your insurance might send the payment directly to you. If so, you must remit full-payment
of the charges to Dr. Cynthia Moorman immediately.
Please sign that you have read and understand our non-contracted insurance policy
Signature of Patient (or Responsible Party, if minor) Date Form Date 06/30/2018
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Cynthia J. Moorman M.D., P.A.
Diplomate of Urology
77 Thomas Johnson Drive, Suite K, Frederick, MD 21702
Phone: (301) 662-4868 Fax: (301) 662-0050
Authorization to Release/Obtain Medical Information
I authorize Cynthia J. Moorman, M.D., P.A. to release/obtain medical history,
laboratory reports, x-rays and any other records regarding medical services
which I have received.
Release To:
Obtain From:
Patient Name: Date of Birth:
Signature Date Form Date 06/30/2018
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Note: The information contained in this facsimile may be privileged and confidential and protected
from disclosure. If the reader of the facsimile is not the intended recipient, you are hereby notified that
any reading, dissemination, distribution, copying, or other use of this facsimile is strictly prohibited. If
you have received this facsimile in error, please notify the sender immediately and destroy this
facsimile. Thank you.
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Completed 9 April 2021

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