Bellevue Urology Associates Inc. PS

Patient Forms

New Patients: Save time – complete your forms before you arrive for your appointment! You should bring a complete list of medications with you to your first appointment. If you have difficulty with any of the questions on any of the forms, fill out what you can, bring the form in with you, and we will help you complete it.

• Patient History Form (12.5 KB)
• Patient Registration Form (20.7 KB)
• Privacy Practices Acknowledgement (12 KB)

If you are a Medicare patient and we believe the services you require are not covered by Medicare, you must fill out an ABN (Advanced Beneficiary Notice) form. This is our committment to you to ensure you understand exactly how much your services will cost.

• Advance Beneficiary Notice (111 KB)

The Voiding Diary is to be competed upon physician request. For your convenience, you may print the diary by opening the voiding diary file:

• Voiding Diary (53.7 KB)

Overlake Hospital Medical Center Women’s Continence Clinic:

• Letter of Introduction (43.1 KB)

If you would like to release your medical records from Bellevue Urology to any other party, you must complete the Medical Records Release form:

• Medical Records Release (7 KB)

Please note: If you would like to fax your forms ahead of time, our fax number is 425.453.2827.

Insurance Companies

Below you will find a list of insurance companies contracted with Bellevue Urology. If you do not see your insurance company on the list and want to ascertain your insurance company will cover your services, please contact us at 425.454.8016.

• Aetna U.S. Healthcare
  • HMO
  • PPO
  • POS
  • EPO (Microsoft)
  • Golden Medicare
• Cigna (All plans except HMO)
• First Choice Health Network
  • PPO
  • POS
  • Triple Option
  • HMO
  • Costco
  • Boeing
  • HealthFirst
  • SeniorsFirst
• Group Health Option (First Choice)
• Labor & Industries (Standard)
• Medicare
  • Standard
  • Railroad
• Great West
  • PPO
  • POS
• Pacificare of Washington
  • Commercial
  • Secure Horizons
  • POS
• PHCS (FirstHealth)
  • PPO
  • POS
  • EPO
• Premera Blue Shield
  • Participating
  • PPO
• Providence (RegenceCare)
• Regence Blue Shield
  • Participating
  • Preferred
  • Selections
  • FEP
  • Basic Health
• RegenceCare
  • Commercial
  • Healthsense
• United HealthCare (PPO)
• Uniform Medical Plan (PPO)