University Physicians Primary Care

University Physicians Primary Care

University Physicians – Endocrine

Ian Herskowitz, M. D.

Leyla El-Choufi, M. D.

Jennifer Pedersen-White, D. O.

Stacey Williamson, PA-C

Thank you for choosing University Physicians – Endocrine Services. We are delighted to welcome you and will make every effort to serve you in a manner that will meet your expectations.

Please assist us by completing the attached forms and bringing them with you for your initial visit. If you need to change or cancel this appointment, please call us so we can offer this date and time to another patient.

Please bring the following items with you to assist with your examination.

  • Any medical records from your referring or previous physician.
  • Picture ID
  • Insurance Card(s)
  • A list of or in the original bottle all of your medication that you are currently taking.
  • Co-payment if applicable.

If your appointment is scheduled for diabetes management you will also need to bring:

  • Your glucose meter
  • A two week record of your blood sugars

Please note that we have located to 1303 D’Antignac Street; which is Professional Building #4, Suite 1200 (located directly across the street of the main entrance of University Hospital) our phone number is 706-774-7760.

On behalf of our entire medical team, we would like to thank you for choosing University Physicians – Endocrine for your health-care needs.

Office Information

Office Hours:

8:00 a.m. – 5:00 p.m. Monday through Thursday

8:00 a.m. – 12:00 p.m. Friday

Contact Information:


706-774-7766 Fax line

706-774-7263 Billing Office

If you need to contact the office after hours, please call the main number and you will be connected to the answering service who will page the on call provider.

Appointments: Patients are seen by appointment only. This allows the provider adequate time to evaluate each patient. As you know, emergencies can come up during office hours that may effect the waiting time. The providers and office staff will do whatever is needed to minimize your inconvenience when such delays occur. In addition the office will accommodate same day appointments whenever possible if you have an acute need.

Cancel or Rescheduling: We ask that you give 24 hours notice, so that we may accommodate another patient during this appointment time. As we do have several patients waiting on a priority list who are in need of an appointment before their scheduled time that are available to come in if there is an open appointment time.

Hospitalizations: University Physicians utilize a 24 hour hospitalist service at University Hospital. Our providers and staff work very closely with the service to ensure that you receive excellent care for your medical concern.

Laboratory: Our practice only utilizes University Hospital to send laboratory/diagnostic specimens. Please let us know if your insurance company uses another preferred laboratory so we may give you an order form to take with you to your preferred laboratory.

Fees: Fees will vary with the complexity of care and tests that may be required for evaluation and treatment of your condition. Our office can provide you with a cost estimate for treatment and our financial policy is included for your information.

Insurance Coverage: Your insurance is filed for all services rendered in this office. If you have a plan that requires a co-payment for your office visit, you will be expected to pay this when you check in for your appointment. After your insurance has paid, you will receive a statement reflecting the balance owed by you and prompt payment is expected. Even though you may have insurance please remember that you are ultimately responsible for payment of services rendered. If you need to set up a payment plan, our billing staff is available to assist. They can be reached at 706-774-7263.

Patient Information

My physician is: Leyla El-Choufi, M. D. Ian Herskowitz, M. D. Jennifer Pedersen, D. O.

Primary Care Physician Referring Provider:  Same or


SSN# Gender Male Female DOB



Home Phone ______Work Phone ______Mobile Phone

Primary number I wish to have used for contact  Home #  Work #  Mobile #


Need Interpreter?  Yes  No Primary Language Marital Status S M D

Ethnicity Religion Race

Emergency Contact Relationship Phone

Preferred Pharmacy

Preferred Laboratory

Employment status Employer:

Guarantor of Account  Self Other: Relationship

Address City ST Zip Phone #

Insurance ID# Grp #

Subscriber:  Self Other: Relationship

DOB SSN # Phone #

All information given is accurate. I give permission for University Physicians to contact me regarding practice information by the above methods.

Print Name

Signature Date

Financial Policy

Please bring with you at the time of your appointment

Thank you for choosing University Physicians. We believe that establishing a written financial policy is mutually beneficial for all parties. It is our goal to avoid any miscommunication or concerns regarding financial matters in order to focus our energies on providing quality healthcare services to our patients. Our financial policy is as follows:

  1. Payment - Payment is expected at the time of service.
  2. Insurance -
  3. Please provide a copy of your insurance card prior to each visit.
  4. We will file insurance for you under most circumstances as long as you provide us with current information. You are ultimately responsible for understanding the details of your coverage and what charges you may incur.
  5. If your insurance company does not respond to us within 60 days of a filed insurance claim, the charges will be sent to you to follow up on and you will be responsible for payment.
  6. Minor Children Patients -
  7. Minor children patients must be accompanied by a parent or legal guardian.
  8. Charges for services rendered to minor children are the responsibility of the parent who seeks treatment for the child and are due at the time of service regardless of court-ordered responsibility.
  1. Self-Pay Patient Discounts - We offer discounts to our self-pay patients (patients who have no insurance coverage) who pay in full at the time of service -
  2. 50% for All Services;
  3. Self-Pay Patient Discounts do not apply to co-pays, co-insurance, and/or deductibles.
  4. Restricted Service – All Account balances must be in good standing prior to receiving additional services. Please contact our office if you are unable to pay your balance.
  5. Missed Appointment Charge - Please notify our office at least 24 hours in advance if you are unable to keep a scheduled appointment or you may be charged a $25 fee.
  6. Additional Service Charges - A service charge of up to $35 may be added for each of the following:
  7. Returned Checks;
  8. Additional forms (i.e. disability forms, MVA, attending Physician).
  1. Past Due Accounts of 60 days or longer may be turned over to a third party for collection, along with collection costs, attorneys’ and court fees. You may also be discharged from the practice.

I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable co-pays and deductibles, are my responsibility.


Patient Printed Name / DOB


Patient Signature or Authorized Person Date


Relationship to Patient


Please bring with you at the time of your appointment

PATIENT NAME: ______DOB: ______

  1. Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations).

Name: Relationship: DOB:

Name: Relationship: DOB:

  1. Please list the family members or significant others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY:

Name: Relationship: DOB:

Name: Relationship: DOB:

  1. Please print the address of where you would like your postcards and/or correspondence from our office to be sent if other than your home.
  1. Please print the telephone number where you want to receive calls about your appointments, lab and x-ray results, other health care information if other than your home phone number:

( )

I am fully aware that a cell phone is not a secure and private line.

  1. Can confidential messages be left on your telephone answering machine?

Yes No

  1. I am fully aware my health information will/may be transmitted by electronic transmission, by secure fax transmittal, by internet or by email for continued health care needs.

______Date ______

Patient Signature (Guardian if under 18 years)

1303 D’Antignac Street, Suite 1200 ~ Augusta, Georgia 30901

706-774-7760 (Fax) 706-774-7766