Gastroenterology West

Transcription

1 Gastroenterology West Welcome to The Oregon Clinic, Gastroenterology West! We are pleased that you have chosen us to provide your gastrointestinal care. Please complete the attached forms and bring with you to your appointment. To help expedite your registration and check-in process, we ask that you please bring your insurance card and photo identification to your upcoming appointment. As well, we strongly encourage you to contact your insurance company prior to your upcoming visit to verify your coverage and benefits for your scheduled appointment(s). If your insurance plan requires a copay, it is due at the time of service. Check-in for your appointment is at The Oregon Clinic, Gastroenterology West, Suite 300. If you do not bring your photo identification, insurance card, and required copay to your scheduled appointment, your appointment will be rescheduled. If you need to cancel or reschedule your appointment, please provide 1 business day notice for office visits and 3 business days notice for procedures to avoid being charged cancellation/rescheduling fees. Multiple missed appointments could result in termination from our practice. Thank you for your time in completing these forms. If you have any questions regarding your appointment(s), please call Sincerely, The staff of The Oregon Clinic, Gastroenterology West CHECKLIST: Detailed list of medications and doses. Insurance card and required copay. Photo Identification. Completed Medical History form. Contact insurance company to verify coverage S.W. BARNES RD. SUITE 300 PORTLAND, OR FAX

2 Acct #: Patient History Form Please answer ALL questions by filling out the appropriate box(es). Name: Gender: M F Primary Care Provider: DOB: Today s Date: Referring Provider (if different from PCP): Chief Complaint-Primary reason for today s visit: Length of symptoms: Have you ever been seen by a GI doctor before? No Yes If yes, please list provider(s): Do you need special accommodations for your exam? No Yes If yes, please describe: Preventative Care Colonoscopy Flexible Sigmoidoscopy Fecal Blood Testing Flu Vaccine Pneumonia Vaccine PCV13 (Prevnar) Page 1 of 6

3 Your Medical History Please indicate whether you have or have had any of the following by filling in the appropriate box(es). NONE Respiratory Genitourinary/GYN Cancer Cardiovascular Asthma Kidney disease Anal Arrhythmia Emphysema/COPD Pelvic organ prolapse Breast Congestive heart failure Sleep apnea Sexual abuse Cervical Deep vein thrombosis Uterine/Cervical disease Colon Heart attack Gastrointestinal Esophageal High blood pressure Barrett s esophagus Ear Nose Throat Head and neck High cholesterol Colon polyp Allergic rhinitis Liver Peripheral artery Crohn s disease Nasal/Facial fracture Ovary disease Diverticulitis Pancreas Pulmonary embolus Gallbladder disease Hematologic/Lymphatic Prostate GERD (reflux) Anemia Rectal Rheumatologic Hepatitis Bleeding disorders Stomach Other arthritis Irritable bowel syndrome Blood transfusion Uterine (endometrial) Rheumatoid arthritis Liver disease Coagulation disorders Other cancer Pancreatitis Psychological Ulcerative colitis Neurological Infections Alcohol dependence Ulcers Migraine headache HIV/AIDS Anxiety Seizure disorder Tuberculosis Bipolar Endocrine Stroke or TIA Depression Diabetes Drug dependence Osteoporosis Eating disorder Thyroid disorders Other mental illness Other disorder(s) not listed above: Page 2 of 6

4 Past Surgical History Please list any previous surgeries in the box below. NONE Have you ever had general anesthesia (breathing tube)? No Yes If yes, were there complications? No Yes (Please describe) Have you ever had IV conscious sedation (no breathing tube)? No Yes If yes, were there complications? No Yes (Please describe) Procedures Please indicate if you have had any of the following procedures: Type Date Facility Bone Density Scan CT Scan MRI Scan Ultrasound Upper Endoscopy (EGD) Current Medications/Supplements/Vitamins What pharmacy do you use? Do you currently take Coumadin (warfarin), Aspirin, Plavix, Pradaxa, Eliquis, or other blood thinners? No Do you take any herbal supplements? No Yes Yes Provide a detailed list of medications/supplements/vitamins with doses, OR bring medication bottles to your appointment. Medication Dose How often taken Page 3 of 6

5 Allergies Please list any medication allergies (lidocaine, penicillin, sulfa, etc.). Medication Reaction(s) Other Reaction (describe) Rash Difficulty Breathing Do you have an allergy to IV Contrast? No Yes Do you have an allergy to Lidocaine? No Yes Do you have an allergy to Latex? No Yes Social History Occupation (current/former): Currently Employed? Full Time Part Time No Marital status? Single Married Partnered Separated/Divorced Widowed Children: # Living Ages # Deceased Ages Patient Habits Caffeine Do you drink caffeinated beverages? No Yes If yes, how many per day? Tobacco/Nicotine Smoking status: Current every day smoker Current some day smoker Light tobacco smoker Heavy tobacco smoker Former Never If current or former smoker, how many packs per day? What year did you start? If former smoker, what year did you quit? Alcohol Do you currently drink alcohol? No Yes If yes, on average, how many drinks per week? Page 4 of 6

6 Marijuana/Recreational Drugs Have you ever used marijuana, IV or other recreational drugs? No Yes If yes, what type? Marijuana Crack/Cocaine Methamphetamines Heroin Other (please specify) Have you ever used by IV, by needle, or by inhaling up your nose? No Yes What year did you start? Have you quit? No Yes If yes, what year did you quit? Family History Are you adopted? No Yes Don t know Father: Mother: Alive Deceased Don t know Alive Deceased Don t know Does anyone in your family have a history of any of the following? Mother Father Sister Brother Daughter Son NONE Cancer Breast cancer Colon or rectum cancer Esophageal cancer Ovarian cancer Pancreatic cancer Stomach cancer Thyroid cancer Uterine cancer Other cancer Gastrointestinal Celiac disease Colon polyps Crohn s Gallbladder disease Irritable bowel syndrome Liver disease Ulcerative colitis Page 5 of 6

7 Review of Systems Fill in the box if you have had one of these symptoms in the LAST SIX MONTHS. NONE General Cardiovascular Urinary Fatigue Ankle/leg/foot swelling Blood in urine Fever Chest pain Problems urinating Loss of appetite Irregular heart beat Unintentional weight loss Skin Gastrointestinal Itching Neurological Abdominal pain Rash/sores Dizziness Black tarry stools Headache Bloating Musculoskeletal Memory loss Blood in stool Back pain Seizures Change in bowel habits Joint pain Sleep difficulty Constipation Joint swelling Diarrhea Eyes Difficulty swallowing Endocrine Blurring Heartburn Cold intolerance Vision changes Jaundice Heat intolerance Mucus in stool Ears Nose Throat Nausea Psychological Dental problems Regurgitation Anxious or nervous Hoarseness Painful swallowing Sad most of the time Mouth sores Vomiting Postnasal drainage Sinus pressure or pain Hematologic/Lymphatic Bleeding problems Respiratory Easy bruising Cough Enlarged lymph nodes Shortness of breath Night sweats Wheezing Other symptoms not listed above: Patient Signature: Date: Page 6 of 6

8 FINANCIAL POLICY Welcome to our Practice. Please take a moment to review our Payment Policies. We require patients to provide a copy of their insurance card, proof of identification and co-payment at check-in for every visit. If you do not have your insurance card, photo ID or co-payment with you at the time of your visit, your appointment may be rescheduled. PATIENT RESPONSIBILITY Patients are responsible for all charges resulting from treatment provided by The Oregon Clinic. Payment is due in full within 30 days of receiving your first statement unless other financial arrangements have been made with the Business Office. Please remember your insurance policy is an agreement between you and your insurance company, and it is ultimately your responsibility to pay for any balance not paid or covered by your insurance company. REQUIRED PATIENT DEPOSITS-PATIENTS WITH COMMERCIAL INSURANCE COVERAGE Patients will be required to pay a deposit one week prior to their appointment/procedure or their appointment/ procedure will be rescheduled. The deposits are as follows: Procedures $500 (Or their unmet deductible, whichever is less, for non-preventative procedures which may be covered at 100%) REQUIRED PATIENT DEPOSITS-PATIENTS WITHOUT INSURANCE We do offer a 40% discount for patients who do not have insurance. Patients will be required to pay a deposit one week prior to their appointment/procedure or their appointment/procedure will be rescheduled. The deposits are as follows: Office Visit $50 (For new or established patients) Procedures $500 CO-PAYMENTS, DEDUCTIBLES AND CO-INSURANCE Co-payments are the amounts your insurance policy requires us to collect with each visit, and are due at the time of service. Patients who arrive without their co-pay may be rescheduled. The deductible is the total amount your policy requires you to pay before they will pay claims on your behalf. We may ask you to pay the estimated, unmet portion of your deductible before services are rendered. The co-insurance is the percentage of the bill that is your financial responsibility according to the contract with your insurance company. We accept cash, check, VISA, MasterCard and American Express. You are welcome to pay through our online payment system on our webpage; PAYMENT ARRANGEMENTS All patients will be required to pay off their balances within 30 days of receiving their first statement unless payment arrangements have been made with the Business Office. Please contact our Business Office at as soon as possible after receiving your statement if payment arrangements are needed.

9 FINANCIAL POLICY Page 2 REFERRALS AND PRE-AUTHORIZATIONS The Business Office will attempt to obtain a referral from your Primary Care Physician if your insurance company requires one. Please be aware that if you choose to be seen before you have received a valid authorization, your insurance company may not pay for the visit. The Business Office cannot guarantee payment for services or coverage of services from your insurance company. If a referral has not been received hours prior to your appointment, your appointment may be rescheduled. INSURANCE BILLING As a courtesy, we will bill your primary and secondary insurances for you. However, primary responsibility for the account is yours. Providing correct insurance billing information is the responsibility of the patient. If your insurance changes, please present your new card at your visit. All of our providers are participating with Medicare. If you are insured directly through the State of Oregon or are insured through the Oregon Health Plan, please bring your current medical card with you to your appointment. If you do not have your insurance card with you at the time of your visit to provide us with valid insurance information, you will be billed for the services, or your appointment rescheduled. CANCELLATION AND RESCHEDULING FEES If you need to cancel or reschedule your procedure, you must notify us within 3 business days of your procedure time. You may be charged a $100 cancellation/reschedule fee for insufficient notice for procedures. If you need to cancel or reschedule your office visit, you must notify us within 1 business day of your office visit time. You may be charged a $50 cancellation/reschedule fee for insufficient notice for office visits. NO-SHOW FEES You may be charged $100 for not showing for your scheduled procedure. You may be charged $50 for not showing for your scheduled office visit. If you have a pattern of no shows and/or late cancellations, you may be terminated from the practice. INTERPRETER FEES If we have arranged for an interpreter for your visit or procedure, the interpreter service requires a 24 hour notice of cancellation. If you do not show or cancel late, you may be billed for the interpreter fee, in addition to the fees above. PAST DUE AND COLLECTION ACCOUNTS We reserve the right to send accounts with balances that have been outstanding over 90 days from the date of service or the date of payment received from your insurance company, whichever is more, to a collection agency. If you have a balance on your account that is more than 90 days old, and over $300, you will be referred to the Financial Counseling Department to make payment arrangements. If any portion of your past due amount has been assigned to a collection agency, we will request that you pay one-half (½) of that collection balance before your appointment is scheduled with our office. The patient s signature (or the signature of the patient s parent or legal guardian) acknowledges that you understand and accept the above information. I have read the above Financial Policy and agree with the terms of this agreement. Print Name Date Signature

10 NOTICE OF REFERRAL RIGHTS AND ACKNOWLEDGMENT THIS NOTICE DESCRIBES YOUR REFERRAL RIGHTS WHEN YOUR HEALTH CARE PROVIDER REFERS YOU TO ANOTHER PROVIDER OR FACILITY FOR ADDITIONAL TESTING OR HEALTH CARE SERVICES. In accordance with Oregon law, when you are referred for care outside of our clinic, we, The Oregon Clinic-GI West, are required to notify you that you may have the test or service done at a facility other than the one recommended by your physician or health care provider. Oregon law says (ORS ): A referral for a diagnostic test or health care treatment or service shall be based on the patient s clinical needs and personal health choices. A health practitioner or the practitioner s designee shall provide notice of patient choice at the time the patient establishes care with the practitioner and at the time the referral is communicated to the patient. The oral or written notice of patient choice shall clearly inform the patient: (a) That when referred, a patient has a choice about where to receive services; and (b) Where the patient can access more information about patient choice. The patient has a choice and when referred to a facility for a diagnostic test or health care treatment or service the patient may receive the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner; If the patient chooses to have the diagnostic test, health care treatment or service at a facility different from the one recommended by a practitioner, the patient is responsible for determining the extent of coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the facility chosen by the patient. A health practitioner shall not deny, limit or withdraw a referral solely because the patient chooses to have the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner. July 2014 Notice of Referral Rights Oregon Medical Association

11 Directions to: The Oregon Clinic, Gastroenterology-West Gastroenterology - West 9701 SW BARNES ROAD, SUITE 300 PORTLAND, OREGON FAX The Oregon Clinic, Gastroenterology-West Peterkort Centre 9701 SW Barnes Road, Suite 300 Portland, Oregon From Downtown Portland on Burnside Road West: Continue straight through the Miller Road intersection on Barnes Road. St. Vincent Hospital will be approximately two miles down on the right side of Barnes Road. Just past the hospital take an immediate right onto Baltic Avenue. Veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Downtown Portland on Highway 26 West: Continue on Highway 26 for six miles to the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From the Oregon Coast: Take Highway 26 East to the Park Way/Barnes Road exit, #69B. At the 1st light, follow the right fork (Blue signs will direct you to the Hospital). Continue straight through the next two signals (you will cross Barnes Road and you must be in the center lane to do so) and veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Washington: Take I-5 South to the 405 southbound exit across the Fremont Bridge. From there, take the Beaverton/Highway 26 West exit. Continue on Highway 26 for six miles and take the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Southern Oregon: Take I-5 North and exit onto Highway 217 North. Stay on Highway 217 for six miles (until it ends). Follow the Barnes Road East sign which will put you onto Barnes Road eastbound. Go to the first light and take a left onto Baltic Avenue. Veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Eastern Oregon: Take I-84 West to I-5 South and stay in the left lanes heading toward Beaverton. Cross the Marquam Bridge and take exit 1-D to Highway 26 West. Continue on Highway 26 for six miles and take the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. toc NPP-MAP 2/14