Dear Urologic Oncology Patient (Name)

Dear Urologic Oncology Patient (name):

Thank you for choosing the UCSF Urologic Oncology Practice for your health care. You have made an appointment with:

Dr. Appointment Date: at: AM / PM Urologic Oncology Practice Assistant / Scheduler: Phone: 415/353-7011 Fax: 415/353-7093 1600 Divisadero Street *********************************************** San Francisco, CA For your first appointment to our Practice, and some follow-up appointments, your Physician will require 94115 one or more forms or Questionnaires to be FILLED OUT IN ADVANCE before they can begin your exam. tel: 415/353-7171 You can receive these forms through regular mail, by e-mail, or by an email link to our internet website. fax: 415/353-7093 Below are detailed instructions about these forms: 1. Patients with NO e-mail ( for all Diagnosis ): If you could not provide us an email address then you have most likely received this letter, the Health Questionnaire, and other forms in your regular postal mail. Please carefully read the instructions in this letter, fill out all enclosed forms and bring them to your next appointment. 2. ‘PROSTATE CANCER PATIENTS ONLY’ Patients with e-mail + internet access: If you provided us your email address, we have emailed you this letter, and the website-link to our online ‘Prostate Health Questionnaire’ will be emailed to you within 48 hours of when we scheduled your appointment. You will receive two emails; one containing your username, and another containing your password. When you log-on to the Questionnaire website you will be required to change the password to your own private password. online ‘Prostate Health Questionnaire’ is designed only for patients with a diagnosis of Prostate Cancer. It takes approx. 45 minutes to fill out, and when completed is automatically returned to us. If you do not receive our email with the online Questionnaire link and password, please call the Practice Assistant listed above.

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Health Insurance, Self-Pay Patients, and Financial Matters at Your Visit

If you have Health Insurance: It is the New Patient’s responsibility to bring a referral or insurance authorization for their New Patient Visit. For some patients, our staff will inform you to obtain separate authorizations for additional services (i.e., ultrasound, biopsy, cystoscopy, or pathology slide review) which may occur at your very first visit. For all NEW Patients who have an HMO Insurance, you must bring us the Referral-Authorization from that Insurance Co., the referring Physician, or from your Primary Care Physician (PCP). Without this referral or authorization, you will be billed for the services. Once you are an established (followup) patient of ours, we will obtain all future authorizations for services which are performed in our Practice or prescribed by our physicians. Bring in your current Insurance Card(s) so we can make copies for your chart. Be sure to inform us whenever you have any changes with your Health Insurance.

Co-Payment: Please be aware that most insurance companies require a co-payment at each visit. Look on your insurance card, it should state what that co-pay amount is.

If you are a Self-Pay patient: - and you will not be using a Health Insurance plan to pay for your services. At your first New Patient Visit a deposit of $345 will be collected when you check-in to see the physician. The deposit fee for future follow-up visits will be $160.00. You will be mailed a bill for the balance due for any services provided during your office visit which exceeded the deposit paid. Payment methods include cash, credit card, or check. The deposit you pay at our Practice is applied only to your exam and services occurring with our physician in our Practice. During your visit, if the physician performs any additional tests or procedures that involve another department (for example the lab, pathology or radiology) you will be billed separately for those additional services by that department. NOTE: UCSF automatically provides a 30% discount to all Self Pay patients.

Urologic Oncology As preparation for certain New Patient Appointments our Physician may require your previous other facility or hospital Pathology slides and Radiology films be reviewed here at UCSF. Charges for a review can 1600 Divisadero range from $400 to $2500. Self-Pay Patients may want a more detailed cost estimate before your Street appointment, if so, please alert the Practice Assistant. For a Pathology slide review cost estimate please San Francisco, CA call (415) 353-1269 (Janice Moore) or (415) 353-1548 (Angela See). For a film review cost-estimate call 94115 (415) 353-1236. You may be asked to make a deposit for these reviews in advance. tel: 415/353-7171 fax: 415/353-7093 If our physician recommends a prostate biopsy procedure, there will be (2) additional charges: First, charges by the physician performing the biopsy in our Practice, and a second charge from the Department of Pathology who will be processing and reviewing the biopsy specimens. A minimum of (8) specimens are usually needed, and the physician may require 14 or more in some instances. For established patients with health insurance, our staff will contact your insurance company for authorization. These charges start at approx: Physicians fee, $900; Pathology charges, $5200. Please speak with the Practice Assistant of the physician performing the biopsy to learn more about these costs.

Many patients have insurance plans with deductibles. UCSF will first bill your insurance plan and if you have not met your deductible, you will receive a bill for that amount determined by your insurance company. We urge all patients to become familiar with their own insurance plan details.

If you have a Health Plan Savings Account (they will have provided you with a card), you must contact your insurance company and inform that you are receiving care at UCSF. Your insurance company will then need to activate the savings card to be used at UCSF. This process typically takes 10-14 days so please schedule your appointment with this in mind.

If at any time you would like to speak to a UCSF Financial Counselor to discuss any concerns, please call (415) 885-7803, and their fax if needed is (415) 885-3505.

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CHECK- LIST: What To Do Before Your First New Patient Visit

1. Collect your recent medical test reports/records and HAND-CARRY them to your appointment (unless we ask you to fax). Please do not bring us your entire medical chart records. These reports include:  Recent XRAY, CT, MRI, or Ultra-sound. Obtain the report and a copy of the scans, films, or CD’s from the location where you had this test, or ask the ordering physician for a copy.  Any recent Pathology (biopsy) slides and the report related to your current diagnosis. You will obtain these from the lab of the hospital or office where you had the test/procedure performed.  Your last lab report. The last written report or dictation from the last visit with your referring physician.  A current list of the medications you are taking.

2. COPIES OF YOUR RECORDS: We are unable to make copies of the medical records you bring us. If you need copies for yourself, please have them made before your visit to our practice. 3. Lastly: we apologize in advance if your appointment start time is delayed. We ask that you be sensitive to a factor that we often cannot control: Patient appointments to a Cancer Specialist Physician can vary in time length. Our physicians try their best to keep to the appointment schedules, but often they encounter healthcare issues that require more time than the appointment slot. Our Physicians strive to give all patients the amount of time needed. If you do encounter a lengthy delay, we apologize and thank you for your patience and understanding of this matter. Important Phone Numbers

Hours Of Operation: Monday-Friday, 9am to 5pm. We are closed weekends and all major holidays.

Urologic Oncology Main Practice Phone...... 415.353.7171 Connects to our service during lunch 12pm to 1pm Front Office Fax...... 415.353.7093 1600 Divisadero Alternate Fax if needed...... 415.353.7094 Street Practice Manager...... Michael Glover, 415.353.7097 San Francisco, CA 94115 During Normal Working Hours: When you call our Main Practice phone you will hear the following tel: 415/353-7171 menu choices: fax: 415/353-7093 Press 1 to learn our address, directions to our Practice, or our Fax number.

Press 2 to speak with Front Office Staff for general information and to make a FOLLOW-UP appointment, and to discuss billing questions.

Press 3 only if you are a Physician calling with an urgent medical situation.

Press 4 if you need to have a Prescription refilled (only for prescriptions originally given to you by our Physicians):

 Have your pharmacy fax us your prescription medication request with your name, birthdate and phone. Make sure your Pharmacy writes our Physician’s name on the faxed request. Our fax number is listed above. When we receive this faxed request, our nurses will call in your prescription and the pharmacy will then contact the patient when it is ready.

Press 5 to reach our Nursing Coordinator Line. Sub-Menu of Nurses  Press 3 for Julie Russell: Nurse for Dr Rosenberg, Dr Fong, Dr Harzstark, Maryanne Christoforou, NP.  Press 4 for Jay Trovato: Nurse for Dr Small, Dr Ryan, Dr Lin, Tammy Rodvelt, NP.  Press 5 if your physician is: Dr. Carroll, Dr Greene, Dr Konety, Dr Meng, or Dr Shinohara Press 6 to have all the above menu choices repeated.

During After-Hours, Weekends, and Holidays: Dial the Main Practice phone listed above and press (1) to be connected to our answering service. The Operator there will deliver your message to the ON-CALL Physician available during after-hours. He or she may not be your usual physician but will be able to give you advice and consult your physician if necessary. During after-hours you may also choose to leave a message on our Practice Voicemail. Messages left on our voicemail during normal work hours will be checked at intervals on the same day. Messages left during after-hours will be retrieved on the following business day.

Location: We are located at the UCSF Comprehensive Cancer Center at Mount Zion, 1600 Divisadero Street, SF, CA 94115 (between Post and Sutter Sts.). A parking garage is located on Sutter St. just west of Divisadero St. When you enter the building our elevators are in the lobby immediately to your LEFT and we are located on the 3rd floor of The Cancer Center.

For directions and additional information about our Practice, please visit our website at http://www.ucsfhealth.org/adult/medical_services/cancer/urologic/index.html

If you experience a Medical Emergency, please dial 911 and request assistance UCSF Comprehensive Cancer Center

Physician Contact Information Affix Patient Label Here * Please fill out this Form and bring to your next appointment *

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Please list all physicians who care for you and their complete addresses so that we can send them updates on the treatment you receive at the UCSF Comprehensive Cancer Center.

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