Commonwealth Urology
JOHN J. BASILE, MD, PC
SUNIL V. PATEL, MD
Adult and Pediatric Urology

Patient Referral/Card Responsibility Form


I, ___________________________________, understand that my insurance company requires a referral to be seen by one of our doctors. The referral is the patient's responsibility and if not received by our office within 48 hours, I will pay for my services.


You must also produce an insurance card to this office within 48 hours from date of service, or you will be responsible for payment in full for our services within 10 days.


Signature: ___________________________________


Date: ______________________________


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Commonwealth Urology
JOHN J. BASILE, MD, PC
SUNIL V. PATEL, MD
3020 Hamaker Court, Suite B-111
Fairfax, Virginia 22031-2220
Tel: 703.876.0288
Fax: 703.876.0290
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