UNIVERSITY GASTROENTEROLOGY, P.C Alcoa Hwy., Bldg. B, Suite 100, Knoxville, TN Phone: (865) Fax: (865)
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1 UNIVERSITY GASTROENTEROLOGY, P.C Alcoa Hwy., Bldg. B, Suite 100, Knoxville, TN Phone: (865) Fax: (865) SCREENING COLONOSCOPY Your physician recommends that you undergo a colonoscopy procedure to screen for colon cancer. The American Cancer Society recommends a colonoscopy for everyone 50 years of age and o lder. A colonoscopy may be recon1mended earlier if you have a family member with a History of colon cancer. A colonoscopy significantly reduces your lifetime risk of colon cancer. University Gastroenterology is dedicated to providing you with the best care and service possible. Our experienced scheduling assistants are available to walk you through the entire screening process. They can answer any questions or concerns you may have while letting you know what you can expect before, during and after your procedure. They will work closely with your insurance company to identify your individual coverage and will communicate any potential coverage issues prior to your appointment. You may hand deliver this packet to our office anytime during normal business hours. A t that time a scheduling assistant will meet with you one on one to answer questions and walk you through the rest of the process. You may mail it to our office along with a current copy of your insurance card(s) to: University Gastroenterology 1928 Alcoa Highway B-100 Knoxville, TN You may f ax it to our office along with a current copy of your insurance card(s) to: Our dedicated physicians and friendly Staff look forward to providing you with exceptional patient care.
2 UNIVERSITY GASTROENTEROLOGY, P.C. Dr. Mark D. Anderson Dr. John A. Stancher Dr. Sangeeta (Sandy) Gulati Dr. Carlos A. Roll h a user Dr. Rama nujan Samavedy Dr. Benjamin P. Dalton 1928 Alcoa Highway, Building B, Suite 100, Knoxville, TN Phone (865) Fa x (865) Last Name First Name Ml Birthdate Social Security Number Have you ever had a colonoscopy by any other Gastroenterologist anywhere in the past? If so, Who? Where? When? MEDICAL HISTORY If you have a preference, please circle the doctor that you would like to see: Dr. Mark D. Anderson Dr. John A. Stancher Dr. Sangeeta (Sandy) Gulati Dr. Carlos A. Rollhauscr Dr. Ramanujan Samavedy Dr. Benjamin P. Dalton D Personal History of Colon Cancer or Polyps? If so, when Family History of Colon Cancer Who? Are you currently having? (Check ail that apply) D Change in bowel habits, 0 Rectal Bleeding 0 Abdominal Pain Other History: (check all that apply) 0 Heart Disease 0 Diabetes 0 Renal Disease 0 Oxygen 0 Heart Valve Disease 0 Hypertension 0 Artificial Hips and/or knees 0 Rheun1atic Fever 0 Bleeding/Clotting Disorder 0 Sleep Apnea/CPAP machine 0 Transplant 0 Pace1naker/Defibrillator, Valves or Stents 0 Endocarditis 0Recent Bypass, within the last year Are you currently taking Coun1adin, Plavix (blood thinners) YES NO (if yes, list below name of medication with prescribing Dr. s name) Are you currently taking a daily aspirin? YES NO (if yes, list dose) List all other medications and dose below: MEDICATION ALLERGIES: PREVIOUS SURGERIES: DO YOU SEE A CARDIOLOGIST? YES NO Who? REFERRING PHYSICIAN PHONE
3 University Gastroenterology, PC Patient Registration PATIENT NUMBER SOCIAL SECURITY # FIRST NAME MIDDLE LAST NAME SEX DATE OF BIRTH MARITAL STATUS: MARRIED O SINGLE O DIVORCED O WIDOWED O EMPLOYMENT STATUS MAILING ADDRESS CITY STATE ZIP HOME WORK ( ) CELL FAMILY DOCTOR NAME OF REFERRING PHYSICIAN EMPLOYED O RETIRED O FULL TIME STUDENT O OTHER EMPLOYER PRIMARY INSURANCE CARD HOLDER'S NAME RELATIONSHIP DOB SOC. SEC. # SECONDARY INSURANCE CARD HOLDER'S NAME REL.ATIONSHIP DOB SOC. SEC. # RELATIONSHIP FIRST NAME SEX LAST NAME HOME WORK ' CELL' PHARMACY PHARMACY NUMBER ----' University Gastroenterology will leave confidential messages on your answering machine, with a family member or other individual answering the phone when you are not at home unless you indicate otherwise. We will safeguard your privacy by limiting the amount of information disclosed. For example, when calling your home we will only leave our name and number and other information necessary to confirm an appointment, or ask you call back. Please contact me as follows: HOME TELEPHONE WORK TELEPHONE o OK to leave messages with healthcare information o OK to leave messages with healthcare information. o Leave message with call back number only. o Leave message with call back number only, o Do NOT leave messages o Do NOT leave messages LIST NAME OF INDIVIDUALS YOU AUTHORIZE US TO SPEAK WITH REGARDING YOUR HEALTHCARE. o None OOther o Spouse o Child If we are unable to reach you by any other means, we will send information through the U.S. Postal Service to your home address. AUTHORIZATION TO RELEASE INFORMATION AND PAY BENEFITS TO PHYSICIAN: I Hereby authorize the physician lo release any information acquired in the course of my treatment necessary to process insurance claims. I also authorize payment directly to the Physician of the Surgical and/or Medicaid Benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay noncovered services. SIGNATURE (Patient or Parent if Minor) DATE
4 University Gastroenterology, P.C. Payment Policy We are committed to providing you with quality and affordable healthcare. Please read the below and ask any questions you n1ay have, and sign in the space provided. 1. Insurance Plans. We arc providers with Medicare, most Aetna plans, Beech Street, Blue Cross Blue Shield of Tennessee, Blue Care, Bowater, Americhoice, Humana, Campus- military only, CIGNA, The Initial Group, PHCS, Preferred Health Partnership (PHP), and United Healthcare. If you are insured by a plan we do business with but do not have an up-to-date insurance card, payment in full for each visit is required until we are provided with a current copy of your insurance information. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions that you may have regarding our coverage. 2. Co-payments. All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company. Please help us in upholding your agreement by paying ng your co-payment at each visit. 3. Referrals. Many patients are now required to obtain referrals or authorizations from their primary care physician (PCP) before receiving treatment from a specialist. It is important that you obtain this from your PCP before coming in for your appointment. Our fax # is Non-Covered Services. Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by your insurance, even though your physician feels that it is necessary. Our office will file each visit with your insurance con1pany. If they deem that something is not reasonable or necessary, we ask that you sub1nit payment for that item. 5. Proof of Insurance. All patients must complete our patient information f01m before seeing a physician. We will also ask that you complete this form once every year. We must obtain a copy of your current valid insurance card to provide proof of insurance. If you fail to provide us with the correct information in a timely manner, you may be responsible for the balance of a claim. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. We will also need to have a copy of your new insurance card. 6. Claim Submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their requests. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. If you have Medicare, we will bill you any moneys owed after we have received payment from Medicare and/or a secondary policy that you might have. 7. Non-payment. If your account is over 90 days past due, you will receive a letter from our billing department. Please be aware that if a balance remains unpaid, we 1nay refer your account to a collection agency. 8. HIPAA. A copy of the UPA Notice of Information Practices has been made available to me. I understand that this notice describes how my health information may be used or disclosed by UPA, physicians and other providers practicing at UPA facilities and that I should read it carefully. I am aware that the Notice may be changed at any time. I may obtain a revised copy of the notice by calling , by visiting or by requesting one from the UPA Office. I have read and understand the payment policy and agree to abide by its guidelines: Patient signature Date A copy of this can be provided to you upon request.
5 University Gastroenterology P.C Alcoa Highway B-100 Knoxville, TN P F Please read and sign in space provided below. A copy of this can be provided to you upon request. We recognize the need for a definite understanding between the patient and the doctor concerning health care and the financial arrangements for this medical care. Our commitment is to provide the ve1y best health care for our patients while recognizing the need to limit services to only those that are necessa1y for each patient. Our fees reflect the time spent by the doctor with you, the patient, the specialized nature of the doctor's training, and the individual diagnostic studies performed. Our fees are comparable to other similarly trained specialists in the community. If you are scheduling a screening colonoscopv, or find that you are in need of one in the future, please understand that the pre-certification we get from your insurance company is only a guideline that you can use. If our physician finds that you need a polyp removed during the procedure he will remove it. In this case, this will change your screening to a diagnostic procedure which could possibly cause your insurance company to pay less than originally stated. Of course, the fees for care during a specialized procedure or hospitalization may be paid on any mutually agreeable basis. Please contact your insurance company with any additional questions you might have concerning your procedure. Please let us know if you are having any particular financial problem - you will find us understanding and patient. I have read and understand the above
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7 UNIVERSITY GASTROENTEROLOGY, P. C Alcoa Hwy. Building B Suite 100 Knoxville, TN Main, (865) Fax, (865) Mark D. Anderson, M.D. Ramanujan Samavedy, M.D. John A. Stancher, M.D. Benjamin P. Dalton, M.D. Carlo, A. Rollhauser, M.D. Jacque Prince, APRN, BC Sangeeta (Sandy) Gulati, M.D Katherine Beck, APRN, BC COLONOSCOPY: WHAT YOU NEED TO KNOW The Affordable Care Act, passed in March 2010, allows for several preventive services, such as colonoscopies, to be covered at no cost to the patient. However, there are strict guidelines used to determine which category of colonoscopy can be defined as a preventive service (screening vs. diagnostic). These guidelines may exclude those patients with a history of gastrointestinal issues from taking advantage of the procedure at no cost. In cases like these, patients may be required to pay co-pays and deductibles. Although your primary care provider may refer you for a screening colonoscopy, you may not qualify for the "Preventive colonoscopy screening" category. Diagnostic/Therapeutic Colonoscopy - Patient has present gastrointestinal symptoms, colon polyps or gastrointestinal disease requiring evaluation or treatment by colonoscopy. Surveillance/High Risk Colonoscopy - Patient is asymptomatic (no present gastrointestinal symptoms) and has a personal history of gastrointestinal disease (such as diverticulitis, Crohn's disease or ulcerative colitis), colon polyps and/or cancer. Patients in this category are required to undergo colonoscopy surveillance at shortened intervals (usually every 2-5 years). Preventive Colonoscopy Screening- Patient is asymptomatic (no present gastrointestinal symptoms), is 50 years old or older and has no personal history of gastrointestinal disease, colon polyps and/or cancer. Patients in this category have not undergone a colonoscopy within the last 10 years. To determine the category of your colonoscopy and approximate insurance benefits, please follow the steps below: Obtain the preoperative CPT and diagnosis codes from the scheduler or medical assistant CPT: Diagnosis (es) Please note that these are not the final diagnosis codes which will be submitted to your insurance. Final codes cannot be determined until after your procedure occurs. Call your insurance carrier and verify your benefits and coverage by asking the following questions: o Is the procedure and diagnosis codes covered under my policy? Yes or No o Will the diagnosis code be processed as: Preventive or Surveillance or Diagnostic o If my procedure will be preventive (screening) procedure, are there age or frequency limitations for my colonoscopy? (e.g., one every ten years over the age of 50, one every two years for a personal history of polyps beginning at age 45, etc.) Yes or No If yes, list limitations here o If the provider removes a polyp or takes a biopsy, will this change my out-of-pocket responsibility? (A biopsy or polyp removal may change a screening benefit to a medical benefit, which means more out-ofpocket expenses. Carriers vary on this policy.) Yes or No
8 OBTAINTHE FOLLOWING INFORMATION FROM YOUR INSURANCE REPRESENTATIVE: Today's Date Deductible Representative's Name Amount of Deductible Met Co-Insurance Responsibility Facility Co-Payment Facility in Network Yes or No Call Reference Number After talking to your insurance provider, you may call the University Gastroenterology Precertification Department at , press option 3 with any questions or concerns. FREQUENTLY ASKED QUESTIONS Can the provider change, add, or delete my diagnosis so that my procedure can be considered Preventative screening? a NO. The patient encounter is documented as a medical record from information you have provided, as well as evaluation and assessment by the provider. It is a binding legal document that cannot be changed to facilitate better insurance coverage. However, if a patient notices an error in the medical record (e.g., date of birth, medication dosage, history notation, etc.) He/she may request a correction/amendment by contact the provider's office directly. What if my insurance company tells me that University Gastroenterology can change, add, or delete a CPT or diagnosis code? If you are given this information, please document the date of the call, name and phone number of the insurance representative to whom you spoke. Then contact your provider's office and ask to speak with the practice manager. The practice manager will facilitate a coding review of your records.
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