ADVANCED GASTROENTEROLOGY RESEARCH & ENDOSCOPY CENTERS
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- Mary Lamb
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1 NEW PATIENT QUESTIONNAIRE Family Physician: Patient s Social Security #: (Social security number mandatory) Address: address: I understand that my will only be used for educational information. Your will never be shared. Telephone Number (Home): (Work): (Cell): Sex: Female Male Date of Birth: Emergency Contact: Phone # and Relationship: Employer: Guarantor: Primary Insurance: Effective Date of Coverage: Policy Number: Group/Plan Number: Address: Phone #: Secondary Insurance: Policy Number: Address: Phone #: Information provided by: INFORMATION verified by AGI employee: PREVIOUS FHCP MEMBER: YES NO If yes, Medical Record Numbe Physician scheduled to see: Appt. Date & Time: Rev
2 DOB: Age: MR#: SS#: Allergies: No Or Yes and to what: (If Yes, please list above) DIABETES ASTHMA EMPHYSEMA COPD BRONCHITIS HEART ATTACK CONGESTIVE HEART FAILURE ATRIAL FIBRILLATION ANGINA / ASVD STROKE MIGRAINES RENAL INSUFFICIENCY GALLSTONES PANCREATITIS CIRRHOSIS VIRAL HEPATITIS AUTOIMMUNE HEPATITIS HEMOCHROMATOSIS ALCOHOLISM STOMACH ULCERS P PUD HERNIAS BOWEL OBSTRUCTION IRRITABLE BOWEL / IBS ESOPHAGITIS ESOPHAGEAL STRICTURE GERD COLON POLYPS DIVERTCULOSIS HEMORRHOIDS ULCERATIVE COLITIS CHRON S DISEASE COLON CANCER BREAST CANCER UTERINE CANCER OVARIAN CANCER OTHER CANCER HEPATITIS BLOOD DISORDER LIVER PROBLEM DEPRESSION SEIZURE DISORDER SOCIAL HISTORY DO YOU SMOKE DO YOU DRINK (ALCOHOL) DO YOU USE DRUGS GI PROCEDURE HISTORY UPPER ENDOSCOPY / EGD COLONOSCOPY ERCP SURGICAL HISTORY CHOLECYSTECTOMY (Gallbladder) TONSILLECTOMY HYSTERECTOMY CABG / ANGIOPLASTY APPENDECTOMY PROSTATECTOMY GASTRECTOMY JOINT REPLACEMENT TUBAL LIGATION BOWEL SURGERY OTHER SURGERY: list below FAMILY Hx / RELATIONSHIP HEART DISEASE DIABETES GALL BLADDER COLON CANCER COLON POLYPS ULCERS LIVER DISEASE OTHER PROBLEMS: list below Continued on next page...
3 DOB: Age: MR#: SS#: Place an X if you have or have had the symptom for the past 12 months: NAUSEA FEVER VOMITING CHILLS DIARRHEA SWEATS CONSTIPATION WEIGHT LOSS ABDOMINAL PAIN CHANGE IN APPETITE HEART BURN / REFFLUX EYE DISORDER JAUNDICE / YELLOW SKIN NECK PROBLEMS BLOATING HOARSENESS LIVER PROBLEMS COUGH STOMACH PROBLEMS CHEST PAIN INTESTINE PROBLEMS IRREGULAR HEART COLON PROBLEMS PALPITATIONS PAIN ON URINATION HEART PROBLEMS DIFFICULTY URINATING POOR CIRCULATION BLOOD IN URINE KIDNEY PROBLEMS HEART MURMUR PROSTATE PROBLEMS SWELLING OF LEGS BLOOD DISORDER BLEEDING DISORDER ANEMIA BLOOD TRANSFUSION SKIN RASH ITCH HEADACHE DIZZINESS DEPRESSION ANXIETY SEIZURE DISORDER OTHER SYMPTOMS:
4 Medical Office Financial Policy Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy that we require you to read and sign prior to any treatment. In addition, all patients must complete our attached information and insurance form before seeing the doctor. Advanced Gastroenterology Centers Medical Billing Department is responsible for processing the billing for medical services rendered to you. If you have a balance due for medical services rendered, you will receive a statement from Advanced Gastroenterology Centers. If you do not have insurance or do not want us to submit your charges to your insurance company, full payment is due at time of service. We accept cash, checks, Visa/MasterCard and American Express. There will be a $25 charge for each returned check. Balances not paid within 60 days from the date of service may be turned over to a collection agency. Regarding your insurance: If the physician you are seeing is a participating provider under your insurance plan and if the services you are receiving are expected to be covered expenses, we will gladly file your insurance claim for you. You will need to present your current insurance card and provide any additional information that may be necessary to file your claim. You will be required to pay the estimated portion of the bill that you will be responsible for at the time of service. Upon receipt of remittance from your insurance company, the remaining account balance will be transferred to your responsibility. You will receive a statement at that point detailing the charges due. This statement balance will be due immediately. Balances that are not paid within 60 days from the statement date may be forwarded to collection. Please be aware that some, and perhaps all, of the services provided may be non-covered services and are not considered reasonable and necessary under the Medicare program and/or other medical insurance. We are committed to providing the best treatment for our patients and our charges are based on what is usual and customary for our area. You are responsible for payment regardless of any insurance company s arbitrary determination of usual and customary rates. Please give at least 24 hours advance notice when canceling or changing appointments. Failure to do so may result in you being charged in full for the appointment. Thank you for understanding our financial policy. If you have any questions or concerns, please speak with a member of our staff or contact the billing office at I have read the financial policy and understand and agree to this financial policy. Signature of Patient or Responsible Party Date /2-03x
5 CONSENT TO CARE: I hereby authorize and consent to care by the physicians of Advanced Gastroenterology including but not limited to any diagnostic testing, examination, diagnostic procedures, surgical and medical treatment or any other care which the physicians deem necessary to my health and well being. I acknowledge that no guarantees have been made to me with regard to this care. CONSENT TO ASSIGNMENT OF BENEFITS AND GUARANTEE OF PAYMENTS: I request that payment of any and all insurance payments due on behalf for services rendered by the physicians of Advanced Gastroenterology be made directly to them or their designee. I further authorize Advanced Gastroenterology to submit Insurance Claims for payment on my behalf. I authorize the release of medical or other intermediaries for this or any future claims. I understand that I may receive billings from outside facilities and laboratories. I understand that I am responsible for and agree to pay charges that are not paid or covered by my Insurance Plan. I know and understand that I am ultimately responsible for any charges for professional services I have received. I have read all of the information on this form and have answered all the questions asked. I acknowledge that all information provided by myself or my responsible party is true and correct. Written consent must be given if any information is to be provided to anyone other than the patient. This includes spouses and children of patients. Verbal Information regarding my condition may be given to: Signature: Relationship: If this consent has been signed by anyone other than the patient, please state the reason the patient was unable to sign. Relationship to patient: Witness:
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Name Date Street Address City State & Zip Home Phone ( ) Sex Age Date of Birth Cell Phone ( ) Email Address Race Primary Language Employer Occupation Work Phone ( ) May we
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 # (
New Patient Medical Information Survey Revised 3/2013
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Patient Information: Name:!!!! Last!!!! First!! Initial! Sex: Date of Birth: Age: SSN: Phone Numbers:!!!!!! Home!!! Work!!!! Cell Patient Address:! Street Address!!! City!!! State Zip Code Race: Black/African
Patient Information. Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Address: Home Away Address: City: State: Zip:
Patient Information Date: Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Male Female Social Security #: Birth Date: / / Age: Local Phone: ( ) Cellular Phone: ( ) Email Address:
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 FORM Account #:
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Winter Park Colon & Rectal Specialists, LLC JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 Winter Park, FL 32792
JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 DATE: PLEASE PRINT NAME: Last First MI GENDER: M F DATE OF BIRTH: AGE: SSN: _ MARITAL STATUS: Single Married Widowed Divorced Separated RACE: White Black
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
PATIENT COPY ONLY. Patient Name:
Patient Name: Appt. Date Start Time: Patient Payment Policy for Gastroenterology Consultants, P.C. Dear Patient, Your insurance company may pay all, a portion, or none of your bill for services performed
Patient Information Form
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PATIENT INFORMATION. First:
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CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA (360)
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PATIENT INFORMATION FULL NAME First M.I. Last CONTACT INFORMATION
PATIENT INFORMATION FULL NAME First M.I. Last DATE OF BIRTH SOCIAL SECURITY # M / D / Y AGE: SEX: MALE or FEMALE STREET APT/SUITE #: CITY, STATE, ZIP City State Zip INSURANCE NAME POLICY/MEMBER ID: HOME
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First Name: MI: Last Name: Address: City: ST: Zip: County: Referring Physician: Home Phn: Work Phn: Cell Phn:
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If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
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Patient Registration Form
Patient Registration Form PATIENT INFORMATION Please Print Last Name: First: M.I. Mailing Address: City: State: Zip Code: Date of Birth: Gender: M F Married Single Widowed Divorced Separated Partnered
PATIENT REGISTRATION
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New Patient Form. Name: DOB: Review of Systems: Do you have any of problems related to the following symptoms? Check the appropriate box.
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Kalpana Thakur, M.D. PA Registration Form
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Do you have or have you ever had any of the following: Circle Yes (Y) or No (N)
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Patient Registration How did you hear about us? Newspaper Friend/Family Website Other: Patient Information Last Name: First Name: MI: Address: Apt #: City: _ State: Zip: Home #: Work #: Emergency #: Birthdate:
CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.
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Dr. Adeeb Dwairy Gastroenterology
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Insurance Information:
Name Address Social Security # Date of Birth City State Zip Sex Marital Status Home Phone # Work Phone # Cell# Employer Occupation Race: Employed: Full Time Part Time Retired Student: Full Time Part Time
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Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
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