30 min. prior to appointment time

Transcription

1 Patient Name: Appointment with: Dr. Appointment Date: / Day of the Week Time of Appointment: / Month / Day Year Suggested Arrival Time: 30 min. prior to appointment time Dear Valued Patient, In order for us to process your visit in a timely manner, it is necessary that you complete your paperwork prior to your arrival on the day of your appointment. Please bring the following: Completed Paperwork Your Insurance Card Your Rx Card Your Driver s License for verification purposes Your Co-Pay, if applicable, is due at the time of service Referral if needed Blood Work / Hospital Stays / CT Scan / MRI Scan / Ultrasound / any other pertinent information that will assist in our physician providing you with the best care Without these documents, we may not be able to provide you with service. INSURANCE We participate with most insurances, however, it is best that you verify with your insurance company if we are In-Network with your insurance carrier (we are listed as division of Allied Digestive Health with the insurance carriers), or if you have outof-network benefits where you would pay for your office visit and the insurance company will reimburse you. Please be advised that we do not participate with Medicaid. CANCELLATION All cancellations must be done within a 24 hours period in order to avoid a penalty fee. We look forward to your visit.

2 REGISTRATION INFORMATION Please completely fill out, date & sign Date PATIENT NAME Last First MI BIRTHDATE AGE Male Female SS# MARITAL STATUS YOU MUST PROVIDE at least one phone number strictly for Appointment Confirmation Calls. No medical information will be discussed. Authorization will remain in effect until our office receives written notification. Please indicate preferences below. Primary Phone Home / Cell / other specify: Yes / No Ok to leave message on phone/with person. Second Phone Home / Cell / other specify: Yes / No Ok to leave message on phone/with person. STREET ADDRESS CITY STATE ZIP How did you hear about our practice? PRIMARY CARE PHYSICIAN / ADDRESS REFERRING PHYSICIAN / ADDRESS PATIENT S EMPLOYER PHONE PHONE WORK PHONE WORK ADDRESS CITY STATE ZIP PRIMARY INSURANCE POLICY/ID# GROUP# EFFECTIVE If Medicare: Part B Start Date (For Primary or Secondary Insurance) CLAIMS ADDRESS CITY STATE ZIP SUBSCRIBER S NAME policy holder BIRTHDATE RELATIONSHIP EMPLOYER ADDRESS CITY STATE ZIP SECONDARY INSURANCE POLICY/ID# GROUP# EFFECTIVE CLAIMS ADDRESS CITY STATE ZIP SUBSCRIBER S NAME policy holder BIRTHDATE RELATIONSHIP EMPLOYER ADDRESS CITY STATE ZIP Pharmacy Name / town Prescription Card Rx Card Number Pharmacy Phone MANDATORY FIELDS Permission given to call with test results, messages from doctor, biopsies, billing etc. to: This permission will remain in effect until we are notified in writing otherwise. You must provide at least one contact. Myself Phone# Answering machine (ok to leave message?): Yes / No Other person/s Relationship Phone# Answering machine: Yes / No Other person/s Relationship Phone# Answering machine: Yes / No FOR MEDICARE ASSIGNMENT OF BENEFITS: I request that payment of authorized Medicare benefits be made either to me or on my behalf to Red Bank Gastroenterology Associates for any services furnished me by Red Bank Gastroenterology Associates. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. PATIENT S SIGNATURE: DATE: FOR ALL OTHER INSURANCE ASSIGNMENT OF BENEFITS: I hereby authorize and instruct any and all insurance companies involved with my healthcare coverage to make payment directly to Red Bank Gastroenterology Associates. This is for the Professional Medical Expense benefits allowable and otherwise payable to me under my current insurance policy as payment towards the total charges for professional services rendered. This payment shall not exceed my indebtedness to the above practice, and I have agreed to pay in current fashion any balance if said professional service charges are over and above this insurance portion of payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any of information pertinent to my case to my Insurance Company or adjuster involved in the case, unless I have made alternative arrangements with respect to this data: PATIENT S SIGNATURE: DATE:

3 PRIVACY PRACTICES ACKNOWLEDGMENT AND CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS I,, hereby authorize RED BANK GASTROENTEROLOGY ASSOCIATES to use and disclose my health information, which specifically identifies me or that can reasonably be used to identify me to carry out my treatment, payment, and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, RED BANK GASTROENTEROLOGY ASSOCIATES can refuse to treat me. I have been informed that RED BANK GASTROENTEROLOGY ASSOCIATES has prepared a notice ( Notice ) that more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment, and healthcare operations. I understand that I have the right to review such Notice prior to signing this consent. I understand that I may revoke this consent at any time by notifying RED BANK GASTROENTEROLOGY ASSOCIATES in writing, but if I revoke my consent, such revocation will not affect any actions that RED BANK GASTROENTEROLOGY ASSOCIATES took before receiving my revocation. I understand that RED BANK GASTROENTEROLOGY ASSOCIATES has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request. I understand that I have the right to request that RED BANK GASTROENTEROLOGY ASSOCIATES restricts how my individual identifiable health information is used and/or disclosed to carry out treatment, payment, or health care operations. I understand that RED BANK GASTROENTEROLOGY ASSOCIATES does not have to agree to such restrictions, but that once such restrictions are agreed to, RED BANK GASTROENTEROLOGY ASSOCIATES must adhere to such restrictions. Signature of patient or patient s representative Date Printed name of patient or patient s representative Relationship to patient APPOINTMENT CANCELLATION/NO SHOW POLICY Red Bank Gastroenterology Associates and the Endoscopy Center of Red Bank require notice for a cancelled appointment. It is not our intent to inconvenience any of our patients, but in order to run our office as efficiently as possible we need to utilize canceled appointments for other patients. If you are unable to keep your Office Appointment, a 24-hour notice is required. If you are unable to keep your procedure appointment, a two business day notice is required. There will be a $75 charge for missed office appointments. There will be a $300 charge for a missed procedure. Signature of patient or patient s representative Date Printed name of patient or patient s representative Relationship to patient

4 Patient Interview Form PATIENT INFORMATION First Name Last Name MRN Date of Birth Age Notes Please check one as your preferred for communications o Personal o Work CONTACT PREFERENCE o Cell number only o Any method o Patient Portal HIPPA compliant o Patient declines to specify o Other RACE Select one or more o White o Black or African American o Asian o American Indian or Alaska Native o Native Hawaiian or Other Pacific Islander o Unknown o Patient declines to specify ETHNICITY o Hispanic or Latino SEX o Male o Not Hispanic or Latino o Patient declines to specify o Female o Other PREFERRED LANGUAGE o English o Spanish/Castilian o Patient declines to specify ALLERGIES o Patient has no known allergies o Asprin Tartrazine only o Penicillins o Eggs o Peanuts o Other: o Patient has no known drug allergies o Codeine Sulfate o Bactrim/Sulfa o Latex o Band-Aids CONSENT TO IMPORT MEDICATION HISTORY I consent to obtaining a history of my medications purchased at pharmacies. o Yes o No o Milk o NSAID s o Kiwi o Morphine o Iodine Injectable Dye

5 2 PHARMACY Name Address Phone CURRENT MEDICATIONS Name Name Name dose dose dose Name Name Name dose dose dose IMMUNIZATIONS Hep A Hep B HPV Flu Vaccine MMR when when when when when Pneumovax Tetanus Varicella Other when when when when DIAGNOSTIC STUDIES / TESTS Abdominal Ultrasound Colonoscopy CT Abdomen/Pelvis EGD ERCP when when when when when EUS Flexible Sigmoidoscopy Mammogram MRI Abdomen/Pelvis Small Bowel Imaging when when when when when Other _ when PREVIOUS PROCEDURES Appendectomy C-Section Cardiac Stent Colon Resection Defibrillator when when when when when Gall Bladder Removal Hysterectomy Lung Surgery Obesity Surgery Pacemaker when when when when when Other when

6 3 PAST OR PRESENT MEDICAL CONDITIONS Acid Reflux Arrhythmia Arthritis Asthma Celiac Disease Cirrhosis Coronary Artery Disease Diabetes Mellitus non-insulin dependent Hepatitis C Irritable Bowel Syndrome Osteoporosis Colon Cancer Crohn s Disease Elevated Cholesterol HIV Kidney Disease Seizures Valvular Heart Disease Colon Polyps Depression Gout Hypertension Liver Disease Sleep Apnea Ulcerative Colitis Congestive Heart Failure Diverticulitis Heart Attack Hyperthyroidism MRSA Stroke (CVA) C.O.P.D. Diabetes Mellitus insulin dependent Hepatitis B Hypothyroidism Osteopenia Transient Ischemic Attack Other SOCIAL HISTORY Occupation Number of Children MARITAL STATUS Single Married Divorced Separated Widowed Civil Union Unknown Other ALCOHOL CAFFEINE Beer Quantity Number Frequency Coffee Soft Drink Tea Chocolate Hard Liquor Wine

7 4 TOBACCO Current every day smoker Smoker, current status unknown Current some day smoker Light tobacco smoker Former smoker Heavy tobacco smoker Never smoker Unknown if ever smoked DRUG USE Recreational Drug Use: Quantity Number Frequency EXERCISE Type Quantity Number Frequency FAMILY MEDICAL HISTORY No knowledge of family history No family history of Colon Cancer Polyps HEALTH STATUS Alive Deceased/Age Cause of Death DIAGNOSES Barrett s Esophagus Breast Cancer Colon Polyps Colorectal Cancer Esophageal Cancer Gynecologic Cancer Liver Cancer Liver Disease Lung Cancer Pancreatic Cancer Prostate Cancer Stomach Cancer Ulcerative Colitis/ Crohn s Disease Mother Father Sister Brother

8 5 CONSENT TO SHARE DATA I consent to having my medical and demographic information shared with other health care entities. Yes No REMINDER OF PREFERENCE I would like to receive preventive care and follow up care reminders. Yes No REVIEWED WITH Patient Parent Guardian Not Present SIGNATURE Signature Date