Gastroenterology Specialists, Inc.
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- Bernadette Anderson
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1 Address: John R. Hood, M.D. Michael J. Martin, M.D. William K. Briggs, M.D. Jeffrey L. Bigler, M.D East 91st Street South Tulsa, Ok (918) Gastroenterology Specialists, Inc. Sheldon C. Berger, D.O. David W. Morris, D.O. Roy L. Thompson, M.D. Geoffrey A. Fillmore, D.O. Social Security Number: - - Last Name: First: MI: Home #: ( ) - Address: Work #: ( ) - City: State: Zip: Cell #: ( ) - I give GSI permission to leave a voic message at this number: Home: Work: Cell: Date of Birth: Marital Status: Gender: Referring/Primary Physician: Emergency Contact Name: Emergency Contact Phone #: ( ) - Primary Insurance: Employer: Relationship to patient: Card Holder s Name: Card Holder s SSN#: DOB: Card Holder s Employer: ID#: Group #: Claim Address: City: State: Zip: Secondary Insurance: Card Holder s Name: Card Holder s SSN#: DOB: Card Holder s Employer: ID#: Group#: Claim Address: City: State: Zip: By signing below, I acknowledge I have received GSI s Privacy Policy, Financial Policy, and Patient Rights & Responsibilities: Please remember that insurance is considered a method of reimbursing the patient for fees paid to the physician and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance. I hereby assign all medical and/or surgical insurance benefits to which I am entitled to Gastroenterology Specialists, Inc. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all changes whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient record, which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS), until otherwise revoked in writing by the patient or guardian. Patient Signature: Date: If preferred, you may wait to sign this form until you receive these policies in our office. GSI s Privacy Policy, Financial Policy, and Patient Rights & Responsibilities are available in our office, by mail if requested, or on our website at: Please bring these completed forms, your insurance card(s), and a photo ID to your appointment. A $50 fee may be charged for missed appointments or appointments rescheduled without sufficient notice.
2 Gastroenterology Specialists, Incorporated East 91st Street South Tulsa, Oklahoma (918) Fax (918) John R. Hood, M.D. Michael J. Martin, M.D. William K. Briggs, M.D. Jeffrey L. Bigler, M.D. Sheldon C. Berger, D.O. David W. Morris, D.O. Roy L. Thompson, M.D. Geoffrey A. Fillmore, D.O. Authorization to Release Medical and Financial Information This authorization covers all services rendered to me, or the patient I am signing for, today and all future dates of service until revoked in writing. I understand I may revoke this authorization by informing Gastroenterology Specialists, Inc. in writing at any time. I authorize Gastroenterology Specialists, Inc. to release any medical or financial information to the individuals and entities listed below including: -All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, photographs. -All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits. I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse, communicable and/or non-communicable disease. I authorize the release or disclosure of this type of information. There are no limitations placed on dates, history of illness or diagnostic and therapeutic information, including any treatment of alcohol/drug abuse, HIV-AIDS, or psychiatric treatment. (Gastroenterology Specialists, Inc. may not release information or records to any individual or entity unless you identify them here): Signature Patient Name Date / / Patient s Date of Birth / /
3 Date of Appointment: Why are you here Please describe in your own words: When did your symptoms start? Are your symptoms: Constant: Intermittent: Were you given any medications for your symptoms? Yes Please list them: Have you ever been on any of the following medications? (check all that apply) Prilosec (prescription or over the counter): Nexium: Protonix: Dicyclomine/Bentyl: Have you ever had (please list date) Aciphex: Prevacid: Hyoscyamine/Levsin/Levsid: Librax: EGD/upper endoscopy: Flexible sigmoidoscopy: Ultrasound of the abdomen: Barium enema (x-ray test): Colonoscopy: CT of the abdomen: Upper GI series (x-ray test): Abdominal x-rays: Page 1
4 Medication Allergies: Medications: ( please list all medications you are currently taking, including any over the counter medications and dietary/herbal supplements) You may attach a written list: Medication Name Dosage/how often When started Do you take (check all that apply) Aspirin: Motrin: Aleve: Medical history (check all that apply ) Heart attack: Heart disease/irregular heart beat: Congestive heart failure: COPD/emphysema: Asthma: High blood pressure: Diabetes: High cholesterol or triglycerides: Thyroid disease: Seizure disorder/epilepsy: Bleeding problems: Blood transfusions: Anemia: Sleep apnea: Alcoholism: Migraine Headache: Cancer: Other: Page 2 Ibuprofen: Advil: Naprosyn: Depression: Anxiety: Bipolar disorder: Panic disorder/panic attacks: Endometrosis: Arthritis: Stomach ulcers: Pancreatitis: Colon polyps: Diverticulosis: Diverticulitis: GERD/acid reflux: Irritable bowel syndrome: Spastic colon: Gallbladder disease: Crohns: Ulcerative Colitis:
5 Surgical history (check all that apply) Gallbladder: Ulcer surgery: Hernia repair: Pacemaker/defibrillator: Appendectomy: Reflux surgery: Hysterectomy: Heart stents: Colon surgery: Gastric bypass: Heart bypass: Heart valve replaced: Other: Have you ever had a bad reaction to anesthesia?: Yes Demerol: Versed: Valium: Fentanyl: Social history: Occupation: Marital status: Hobbies: Do you smoke: Yes How much: Do you use alcohol: Yes How much: Do you use oral tobacco: Yes How much: Page 3
6 Family history: (check all that apply and indicate which family member) Colon cancer: Colon polyps: Stomach cancer: Esophagus cancer: Pancreas cancer: Liver cancer: Breast cancer: Ovarian/uterine cancer: Crohn s disease: Ulcerative colitis: Irritable bowel: Stomach ulcers: Gallbladder disease: Hepatitis: Celiac disease/wheat allergy: Other: Cirrhosis: Do you have an Advanced Care Plan, Living Will or a Surrogate decision maker: Yes Page 4
7 Full Name: DOB: Review of GI symptoms (check all that apply to you) Weight loss: How much? When did weight loss start: Decreased appetite: Abdominal pain after eating: Abdominal pain improved by: Fever: Belching: Passing gas: Eating: Bowel movement: Location of abdominal pain: Upper: Lower: Right: Left: Around belly button: Nausea after eating: Vomiting after eating: How long after: How long after: Heartburn: Day: Night: Both: Reflux: Day: Night: Both: Difficulty swallowing or food getting stuck when you swallow: Jaundice: Abdominal pain associated with constipation: Bloating: Number of bowel movements per day: Do you travel outside the country?: Have you had antibiotics recently (within the last 6months)?: Bloody diarrhea: Constipation: Mucous with stool: Diarrhea: Diarrhea that wakes you up at night: Do you consume well water or fresh water on a regular basis?: Red blood in or with your stool: Black stools: Do certain foods make your abdominal symptoms worse? Yes (If yes, please list) Page 5
PRIMARY INSURANCE TO FILE SECONDARY INSURANCE TO FILE
Social Security #: Date: Full Name: Street Address: City: State: Zip: Mailing Address: City: State: Zip: Home Phone #: Employer/School: Employer Address: Date of Birth: Occupation: Work Phone #: Email:
PATIENT REGISTRATION
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ADVANCED GASTROENTEROLOGY RESEARCH & ENDOSCOPY CENTERS
NEW PATIENT QUESTIONNAIRE Family Physician: Patient s Social Security #: (Social security number mandatory) Address: e-mail address: I understand that my e-mail will only be used for educational information.
First Name: MI: Last Name: Address: City: ST: Zip: County: Referring Physician: Home Phn: Work Phn: Cell Phn:
PATIENT INFORMATION First Name: MI: Last Name: Address: City: ST: Zip: County: Email: Referring Physician: Home Phn: Work Phn: Cell Phn: Social Security #: Drivers License #: Age: BirthDate (mm/dd/yy):
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Stark County Surgeons, Inc Patient Information. Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - -
Today s Date: / / Patient Information Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - - Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Other phone: ( ) - E-Mail
One Stop Medical Center Tel:
PATIENT DEMOGRAPHICS TODAY S DATE PATIENT NAME BIRTHDATE AGE SEX M F ADDRESS CITY STATE ZIP HOME#( ) CELL#( ) WORK #( ) May OSMC leave a message on your: Home Phone: y n Work: y n Cell : y n MARITAL STATUS
Patient Information Form
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Secondary Insurance Carrier Name of Insured Member ID# Group # Birthdate of Insured / / Employer SS # of Insured / / Relation to Insured
PATIENT MEDICAL & PAYMENT INFORMATION SHEET TODAY S DATE Patient Name Date of Birth: / / Age Local Address Social Security # / / City State Zip Code Home Phone # ( ) - Permanent Address Cell Phone # (
PATIENT INFORMATION. First:
PATIENT INFORMATION Patients last name: First: MI: Street Address: PO Box: Birth date: / / City: State: Zip Code: Marital status: Sex: Male or Female Social Security: 1st phone: 2nd phone: Email address:
PATIENT INFORMATION & PREFERENCES (Please print or type) YOUR MAJOR HEALTH CONCERNS OR QUESTIONS
Dear Patient: The following questions are designed to collect important information about you and your health. Answering these questions before your office visit will allow more time for a detailed discussion
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
Signature: Print Name: Date:
~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse
The missed appointment payment may be required prior to, or upon the next scheduled procedure or office visit.
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Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
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Winter Park Colon & Rectal Specialists, LLC JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 Winter Park, FL 32792
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SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
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Obstetrics and Gynecology 50 Medical Drive Suite 100 (806) Borger, TX
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Your appointment is scheduled for at. Please complete this form and bring it with you at the time of your appointment. Last Name: First Name: M.I.
Dear Patient: The following questions are designed to obtain some general information about your medical problems. As a result of answering these questions more time will be available for detailed discussion
Today s Date: Name: Birthdate: / / SS#: Home #: Work #: Cell #: Best Time to Contact You:
Today s : Name: Nickname: Male Female Birthdate: / / SS#: Email: Home #: Work #: Cell #: Best Time to Contact You: Preferred Method of Contact: Please choose all that apply. Home Work Cell Text Email Address:
ROBERT H. OLIVER, M.D., PLLC Otolaryngology Head And Neck Surgery Otolaryngic Allergy Chart #
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PATIENT REGISTRATION SOCIAL SECURITY NUMBER:
PATIENT REGISTRATION LAST NAME FIRST NAME MI M/F ADDRESS APT CITY STATE ZIP BIRTHDATE AGE MARITAL STATUS HOME PHONE SOCIAL SECURITY NUMBER: OCCUPATION: EMPLOYER NAME: WORK ADDRESS: WORK PHONE: PLEASE INDICATE
Welcome to Bay Area Gastroenterology Associates. We look forward to caring for you. To better serve you, please complete the information below..
1 Welcome to Bay Area Gastroenterology Associates. We look forward to caring for you. To better serve you, please complete the information below.. Patient name: Marital Status: Single Married Divorce Widowed
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
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Medical History Patient Information : Name DOB Age Ht: ft. in Wt: lbs. Gender: Marital Status Procedure(s) you are considering:
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby give my consent for Dr. Marisa Lawrence to use and disclose protected health information (PHI) about me to carry out treatment,
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made. Name: Jr. Sr. Last First Middle Prefer to be called: Married Single Date of Birth / / Patient
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided. Last Name: First Name: Primary Care Physician: Referring
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PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
PATIENT: PREFERS: LAST, FIRST, MI GENDER: F M MARTIAL STATUS: SINGLE MARRIED OTHER SOCIAL SECURITY:
(PLEASE PRINT CLEARLY) Date: PATIENT: PREFERS: LAST, FIRST, MI GENDER: F M MARTIAL STATUS: SINGLE MARRIED OTHER SOCIAL SECURITY: HOME PHONE: CELL PHONE: WORK PHONE: WHAT PHONE NUMBER IS BEST TO GET A HOLD
The comfort of home, the care of professionals
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