Orange County Urology Associates, Inc.
A MEDICAL GROUP
25200 La Paz Road, Suite 200
Laguna Hills, CA 92653
(949) 855-1101 fax (949) 855-8710
Vasectomy Questionnaire
Patient Name:
Occupation:
Referred by:
Marital History:
1. Wife’s Name:
2. How long have you been married?
3. How many children by this marriage?
4. Children by previous marriage?
Urologic History:
1. Have you had any injury to the genitals?
2. Have you had groin or testicular surgery?
3. Have you had a urinary or genital infection?
4. Do you have difficulty with urination?
5. Do you have a history of urethral stricture?
6. Have you had prostatitis or prostate disease?
7. Have you had kidney stones?
8. Do you have problems obtaining erections?
Age:
Date: _____/_____/_____
Age:
None
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
General Medical History:
1. Any serious medical conditions under treatment?
If yes please list:_________________________________________
2. Any previous surgery?
If yes please list:_________________________________________
3. Do you take any prescribed medications?
If yes please list:_________________________________________
_________________________________________
4. Do you have any known bleeding disorder?
5. Are you allergic to any medications?
If yes please list:_________________________________________
_________________________________________
6. Have you ever had any reaction to novocaine, anesthesia or local anesthesia?
7. Do you have sleep apnea?
Additional questions
1. Has either spouse been treated by a psychiatrist for mental health problems or
disorders?
2. Are there any serious marital problems?
3. Do you have any questions about the vasectomy procedure or about the information
you have been given to read?
4. Is there any religious issue or conflict for you to resolve before proceeding with a
vasectomy?
5. Do you have any fear vasectomy will diminish your manhood or affect future sexual
enjoyment?
6. Do you wish to be permanently sterile?
Patient Signature: _____________________________
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
No
Date: ____/____/____
Form Revised on 11/04/2008
PATIENT NAME: __________________________________
For Doctor Only
Vital Signs:
BP _________/__________mmHg Pulse _________ bpm
Temp ______° F
WNL ABNL Comment & description of exam
General Appearance
Abdomen:
Genitalia:
Prostate & Rectal:
Other:
Penis
Scrotum
Left Testes
Right Testes
not indicated
Signature: _____________________________ MD
Date: ____/____/____
The patient was informed of the indications for the vasectomy including the desire for permanent
sterilization. Alternative forms of contraception were reviewed and offered and the risks of
vasectomy were explained including but not limited to bleeding, infection, pain and swelling, scar
tissue formation, formation of sperm granuloma and antisperm antibody and the rare possibility of
failure to permanently achieve sterilization. The patient had the opportunity to view the vasectomy
information video.
Signature: _____________________________ MD
Date: ____/____/____
Date of Vasectomy: ______/______/______

POST VASECTOMY SEMEN ANALYSIS

Date: _____/_____/_____ Dr: ____________
Date: _____/_____/_____ Dr: ____________
NO SPERM SEEN
________________ SPERMATOZOA
NO SPERM SEEN
________________ SPERMATOZOA
COMMENTS:_________________________
_____________________________________
COMMENTS:_________________________
____________________________________
Initials: _________

POST VASECTOMY SEMEN ANALYSIS
POST VASECTOMY SEMEN ANALYSIS
Initials: __________

POST VASECTOMY SEMEN ANALYSIS
Date: _____/_____/_____ Dr: ____________
Date: _____/_____/_____ Dr: ____________
NO SPERM SEEN
________________ SPERMATOZOA
NO SPERM SEEN
________________ SPERMATOZOA
COMMENTS:_________________________
_____________________________________
Initials: _________
COMMENTS:_________________________
____________________________________
Initials: __________
Form Revised on 11/04/2008
Orange County Urology Associates, Inc.
Financial Policy
YOU WILL BE RESPONSIBLE FOR PAYMENT IN FULL AT THE TIME OF YOUR VISIT IF COMPLETE
INSURANCE IS NOT PROVIDED. Your initial visit can range from $100 to $300. Here are some hints to help you get
your insurance information ready for your visit:
PPO plan (We are not contracted with HEALTH NET PPO, GREAT WEST PPO):
1. Are we contracted with your insurance company?
• YES – You will be asked to pay your co-payment and deductible.
• NO – You will be required to pay in full. Your insurance will be billed for your reimbursement.
HIGH DEDUCTIBLE PLAN
1. Have you met your deductible? If yes, what percentage are you required to pay on each visit?
• You will be asked to pay the percentage indicated by your insurance plan and deductible at the time of your
visit.
HMO, EPO, POS OR MANAGED CARE PLANS
1. Has your primary care physician AUTHORIZED your visit?
• Visits with prior approval. If your plan requires a co-pay, you will be required to pay this at the time of your
visit.
• Visits without prior approval. You will be required to pay in full at the time of your visit.
OUT OF NETWORK
1. You will be required to pay in full for your visit.
MEDICARE
1. Have you met your deductible?
• You will be required to pay your percentage and any portion of deductible that has not been met.
SECONDARY INSURANCE
1. We will collect your co-payment and co-insurance amounts at the time of your visit.
2. We will be happy to bill your secondary insurance for your re-imbursement.
Medi-Cal, CalOptima, MSI, HEALTH NET PPO, GREAT WEST PPO
1. We are not contracted with these insurance plans. You will be asked to pay in full at the time of your visit.
NO insurance
1. You be required to pay in full for your visit.
We suggest you verify your benefits with your insurance plan prior to your visit.
Effective May 1, 2009 the Federal Trade Commission (FTC) has implemented a new regulation known as the
Red Flag Rule requiring physicians to develop and implement identity theft detection and prevention programs.
TO PROTECT YOU AGAINST IDENTITY THEFT we are required to ask for a photo ID, and a second type
of identification.
I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY FOR ORANGE COUNTY
UROLOGY ASSOCIATES, INC.
_____________________________
Print Name
_____________________________
Signature
__________________
Date
Point of Service Option
Welcome to Orange County Urology Associates, Inc., A Medical Group. We understand that you have chosen to use your
Point of Service (POS) option rather than your HMO for our services. The plan you have allows you this flexibility of
benefits, and we are pleased you have chosen us as your provider of care.
Please note: If you choose to use your POS option on your initial visit, all services provided from that point forward
will be at the POS option. If at any time you wish to revert to your HMO insurance option for urological service
you will be asked to transfer your care to a urology office that accepts your HMO contract.
Please do not hesitate to discuss any questions you may have with our staff regarding this policy.
I wish to establish a relationship with the physicians of Orange County Urology Associates, Inc. A Medical Group, using
my Point of Service Insurance Option. I understand that Point of Service becomes the effective contract between Orange
County Urology Associates Inc. and myself. I further understand that Orange County Urology Associates, Inc. will not
contract with me under the HMO option of my insurance.
I understand accepting this means that I am aware I may have a deductible and/or co-insurance.
_______________________________________________
Name
_______________________________________________
Witness
_______________________________
Date
Orange County Urology Associates fnc.
A Medical Group
PaulA. Brower, M.D.. F.A.C.S
Terrence D. Schuhrke,M.D., F.A.C.S.
Richard A. Cerruti, M.D.. F.A.C.S. Karan J. Singh, M.D.
Richard H. Greengold. M.D.
Aaron Spitz. M.D.
Jennifer L. Gruenenfelder. M.D.
J. Bradley Taylor. M.D.. F.A.C.S.
Moses M. Kim, M.D., Ph.D.
Neyssan Tebyani, M.D.
James P. Meaglia. M.D.
Josh M. Randall, M.D.
NOTICE OF THE USES AND DISCLOSURES OF
PROTECTED. HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are required by federal law to maintain the privacy of your Protected Health lnformatlon. and to
provide you with notice of our legal duties and privacy practices regarcling Protected Health lnformation.
'Protected Health lnformation' is information that we keep in electronic, paper or other form, including
demographic information collected from you and is created or received by us and relates to your past,
present, or future physical or mental health or condition, the provision o'f health care services to you,
or the past, present. or future payment for the health care services we deliver to you, and that identifies
you or which we reasonably believe can be used to identify you.
We are required by federal law to comply with the terms of this notice. We reserve the right to make
changes in our privacy practices.regarding your Protocol Health lnformation. lf we change our privacy
practices, that change will apply to all Protected Health lnformation that we maintain about you. Howevel
before we change our privacy practices, we will provide you with written notice of any changes.
We may use and disclose vour Protected Health lnformation
1.
Treatment: We may disclose your Protected Health lnformation to another
physician such as a specialist, to whom we refer you for medical treatment.
2.
tlealth Care Ooerations: We may disclose your Protected Health lnformation to a
health plan. managed care plan, individual practice association or to a management services
organization that analyzes our delivery of medical services to evaluate our health care quality
management, case management or professionalcompetence, We may also provide your Protected
Health lnformation to other health care providers, such as laboratories or ambulance companies, for
purposes of their health care operations.
3.
Pavment:We may disclose your Protected Health lnformation to obtain paYments.
(a) disclosure to a health plan to determine vour eligibility or
coverage under the plan; (b)disclosures to a health plan to obtain reimbursementfor delivering
medical services to you; (c) disclosures to billing services or collection agencies; (d) disclosures for
utilization management and determinations of whether the medical services we deliver to you are
necessary or appropriat€; or (€) disclosures to determine whether the amount we charge you for
medical services are justifiable.
Disclosures
'
for a varieW of purposes. For example:
4.
for "payment" include:
Reminders and Treatment Alternatives: We may contact you to provide you with
appointment reminders or information about medical treatment alternatives or other health-related
benefits and services that may be of interest to you.
Bev. 1/06 Form OCl19/Pg
1
We may use or disclose your Protected Health lnformation in connection with treatment, payment, or
health care operations if we deliver health care products or services to you based on the orders of another
health care providet and we report the diagnosis or results associated with the health care services directly.to
another health care provider, who provides the products or reports to you. We may use or disclose your
Protected Health lnformation that was created or received in emergency treatment situations, to carry out
treatment, payment, or health care operations if we attempt to obtain your consent as soon as reasonably
practicable after the delivery of such treatment,
We May disclose your Protected Health lnformation without your authorization in the foltowing
circumstances: (a) for public health activities, such as controlling communicable diseases, reporting child abuse
or neglect, to monitor or evaluate the quality, safety or effectiveness of FDA-related products or services; (b)
for reporting'victims of abuse, neglect or domestic violence; (d for health oversight activities, such as overseeing government benefit programs; (d) in response to judicial or administrative orders, such as subpoenas; (e)
for law enforcement purposes, such as rnanOatory reporting of certain types of wounds, or identifying or
locating individuals; H for certain research purposes; (g) to avert a serious threat to the health or safety of an
individual or the general public; and (h) for selected governmental functions, such as national security. ln each
of these situations we will keep records that explain our attempt to obtain your consent and the reason why
consent was not obtained.
We are required to disclose your Protected Health lnformation; (a) to you upon your request; and (b)
to the U.S. Department of Health and Human Services ('DHHS") when DHHS investigates to determine whether
we are complying with federal law.
We may disclose your name, your location in our facility, your general condition and your religious
affiliation. if any, in our facilities directory unless you object verbally or in writing.
ln all other circumstances we must obtain your authorization to use or disclose your Protected Health
lnformation. You will be required to sign an authorization form which permits us to use and disclose your
Protected Health lnformation for certain purposes, and we may not condition the delivery of medical treatment to you on Vour providing the requested written authorization. You have the right to revoke your authorization in writing as long as we have not acted in reliance on the authorization
You have the following rights with respect
1.
2.
to your protected Heatth tnformation:
The right to request restrictions on our use and disclosure of your Protected Health lnformation
for treatment, payment or health care operations. tf we agree to any restriction, then we cannot
violate that restriction except in the case of emergency treatment. However, we are not required
to agree to any restrictions.
The right to request in writing and to receive confidential communications of your Protected
Health lnformation by alternative means (such as by mail or email) or at alternative locations (such
as your office or business workplace).
3. The right to request in writing access to our office to inspect and copy your Protected Health
lnformation. Except in cases where the Protected Health lnformation is not maintain'ed or
accessible on-site, we will act on a request for access no later than thirty (30) days after we
receive your request.
4.
5.
to request in writing that we amend your Protected Health tnformation. Your request
must contain the reasons to support the requested amendment. We will act upon your request
within sixty (60) days after we receive your request.
The right
The right to receive an accounting o'f all our disclosures of your Protected Health lrformation in
the six years prior to the date of your request, except for disclosures: (a) to carry out treatment,
payment and health care operations; (b) to you; (d for our directory or to persons involved in
your care; (d) for national security or intelligence purposes; (e) to correctional institutions or law
give to us; or (g) that
enforcement officials; (f) pursuant to any written authorization that You
occurred prior to April 14, 2003.
6.
The rlght to request and obtain from us a paper copy of this notice.
you believe that we have violated your privacy rlghB, fien-yoqm.a.y file a written complaint with the
privacy gfficer. you may also file a complaint with the Office for Civil Rights of the DHHS. Your
(b) name the Company and describe
compf'aini must: (a) be in writing, eithei on paper or electronically;
good cause
the act or omisslon complainedof occurs, unless the time limit is waived bY the DHHS for
Human
and
Health
of
U.S.
Department
Rights,
Civil
shown. The complaint may be sent to: Office of
retaliate
not
will
We
CA94402.
Francisco,
San
522,
Room
Plaza,
Nauons
Unlied
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Services. Region
the
matters
oF
any
about
igainlt'you i;r filing a iompiaint. tf you wish to obtain additional information
pa\
at
855-1101.
Officer
discussed in this notice You maY contact the Privacy
f
Thls notice is effective as of.April 1. 2005
ACKNOWLEDOEMENT OF RECEIPT OF NOTICE OF USES AND DISCLOSURES OF
PROTECTED HEALTH INFORMATION FOR
ORANGE COUNW UROLOOY ASSOCIATES INC'
Paul A. Brower, M.D., F.A.C.S
Richard A. Cerruti, M.D.' F.A.C.S.
Richard H. Greengold, M.DJennifer L. Gruenenfelder' Ir{.D.
Moses
M. Kim, M.D.,Ph.D.
James P. Meaglia, M.D.
Terrence D. Schuhrke, it{.D.' F.A'C.S.
Karan J. Singh, M.D.
Aaron Spitz, M.D.
J. Bradley Taylor, M.D., F.A.C.S.
Neyssan Tebyani,
M.D.
Josh NI. Randall, M.D.
of the Uses and Disctgsures of Prot-ected Health lnformation (the 'Noticd')
that ls posted in your office. I was informed that I may also obtain a printed copy of the notice from Vour
I have read the Notice
receptionist.
Print Your Name
Sisned
Date
Rev 1106 Form OC119/Pg 2