Meritus Digestive Health Specialists 11110 Medical Campus Road, Suite 246 Hagerstown, MD 21742 Phone: 301-665-4585 Toll Free: 877-835-8827 Fax: 301-665-4587 MeritusHealth.com/MMG Dear Patient: It is with pleasure that I welcome you to Meritus Digestive Health Specialists. We will strive to exceed your expectations and provide you with the best service possible. Should you have any questions please do not hesitate to give me a call. To help your first/returning visit with Meritus Digestive Health Specialists go as smoothly as possible please assist us by bringing the following with you: Completed and signed patient registration and history forms. (Attached) Current insurance cards and Picture ID. Insurance referral form, if necessary. Current medications, including vitamins and supplements, with the original bottle or a complete list with strengths and dosage information. A calendar to help with the scheduling of any testing or procedures the doctor may order. Co-payments are collected on the day of your appointment before you see the physician. We accept cash, checks, Visa, MasterCard, Discover, and American Express. If you are unable to make your payment, your appointment will need to be rescheduled. Please review the attached Important Information For Our Patients sheet, once again if you have any questions please do not hesitate to give me a call. Sincerely, Anne Rice, CMPM Office Supervisor Patient s Name: Appointment Date and Time: Physician: Hemant Chatrath, M.D. Nelson L. Ferreira, M.D. Kiran Khosa, M.D. Juan A. Tayler, M.D. MDHS-28 12/16
Health History Questionnaire Name: Date: Date of Birth: Current Medical Conditions Reason for current visit: Please describe any special problems that you would lilke to discuss with your doctor today: Current / Past Illnesses: Current Past Approximate Date Current Past Approximate Date Weight loss/gain (past year) Blood Transfusions Headaches/Migraine Anemia/Blood Disorder Valve Dis. Heart Dis. Rheumatic Dis. Varicose Veins/Phlebitis Hypertension Skin Disease Respiratory Disease (TB/Asthma) Diabetes Breast Disease Night Sweats Jaundice/Hepatitis Thyroid Disease Gall Bladder Disease Cancer (Type) H.Hernia/Peptic Ulcer (Type) Bowel Disorders Epilepsy/Neurological Dis. Kidney Disease/Infection Arthritis Urinary Incontinence Psychiatric Urinary Infections Surgical History and Other Hospital Admissions Date Reason for Admission Surgical Procedure: Anesthesia Complications: Yes / No Type: Family History Cancer Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Kidney Disease Emotional / Psychiatric Problems Living Deceased Family History Asthma Breast Disease / Cancer Migraine Headaches Birth Defects Osteoporosis Bleeding/Blood Disorders Endometriosis Living Deceased
Social History Diet: Yes / No Type: Exercise: Yes / No Type: Smoking: Yes / No # Cigarettes per day: Alcohol: Yes / No # Drinks per week: Illegal Drugs: Yes / No Domestic Violence: Yes / No Recent / Past Psychological / Sexual / Physical Medications: List ALL current medications Name of Medication Dosage Frequency Name of Medication Dosage Frequency Allergies: For Female Patients Only Please check if you have experienced any of the following in the last 6 weeks: Abnormal Bleeding During Periods Between Periods After Intercourse Abnormal Pap Smear Breast Tenderness/Lumps Burning on Urination Heavy Pressure in Vagina or lower abdomen Comments Loss of Urine when coughing HIV + or sneezing Low Abdominal Pain During Periods Between Periods Uterine Fibroids Hot Flashes/Night Sweats Depression Thyroid Low Back Pain Pain/Difficulty with Intercourse Pelvic Inflammatory Disease PMS Sexually Transmitted Diseases Chlamydia Gonorrhea Syphillis Herpes Genital Warts/HPV Hepatitis Vaginal Discharge/Irritation Endometriosis Infertility Sexual Problems Heavy Menstrual Flow Comments Gynecological History: Age at First Period: First Day of Last Period: Period Interval: #Days Between Periods Duration of Bleeding Cramps: Yes / No Medication for Cramps: Yes / No Number of Periods in Last Year: Date of Last Pap Smear: Results: Normal / Abnormal Date of Last Mammogram: Results: Normal / Abnormal Breast Self Examination: Yes / No Need Instruction? Yes / No Current Method of Contraception (Including vasectomy and tubal ligation) Pill Brand: Problems: Yes / No days Obstetrical History: Past pregnancies including miscarriages or abortions DATE MO/YR GA WEEKS LENGTH OF LABOR BIRTH WEIGHT SEX M/F TYPE DELIVERY ANES. PLACE OF DELIVERY PRETERM LABOR YES/NO COMMENTS/ COMPLICATIONS
Meritus Digestive Health Specialists 11110 Medical Campus Road, Suite 246 Hagerstown, MD 21742 Phone: 301-665-4585 Toll Free: 877-835-8827 Fax: 301-665-4587 MeritusHealth.com/MMG Important Information For Our Patients Meritus Digestive Health Specialists is located in Suite 246 (2 nd floor) of the Robinwood Medical Center. You can use the blue or silver entrance for the nearest parking to the office. Our regular office hours are Monday through Friday 8am. to 4:30pm. Our telephones are on from 8am - 4pm. During your first visit there are no procedures/tests performed. Your procedures or any pre-op tests will be scheduled during this first visit. All directions for the procedures, and questions you may have will be reviewed with you before you leave. A physician is on call 24 hours a day, 7 days a week for your convenience. Please remember the after hours answering service should only be used for emergencies or urgent issues. For prescription refills please call the office at 301-665-4585. Please allow 2 business days for prescription refill requests to be completed. You may contact your pharmacy if you wish to confirm that your prescription is ready. During your office visits please remind us if you are low on any medication and need refills. This office cannot provide treatment if we do not have your referral. If you do not have your insurance referral form at the time of your visit you will have to reschedule your appointment. This only applies if your insurance requires a referral. Please notify our office if there are any changes to the following information: home address, telephone numbers, insurance information, or primary care physicians. We understand that Maryland has a Social Security Number Privacy Act. We are in compliance, and under this law we DO have the right to use this number for internal verification and/or administrative purposes. We are continually striving to improve our services for our patients. Should you at any time have any questions or concerns during your treatment with our office please contact Anne Rice, our office supervisor at 301-665-4585. Hemant Chatrath, M.D. Nelson L. Ferreira, M.D. Kiran Khosa, M.D. Juan A. Tayler, M.D.
Meritus Digestive Health Specialists Medical Practices of Antietam, LLC Thank you for choosing our practice! We believe that establishing a written financial policy is mutually beneficial for all parties. It is our goal to avoid any miscommunication or concerns regarding financial matters in order to focus our energies on providing healthcare services to our patients. We participate with most insurance plans. Each plan has different benefits for you as well as different financial obligations. Not all insurance policies cover all services. It is your responsibility to check with your insurance company to determine covered benefits, and provide referral at the time of your appointment. The following are our financial guidelines relative to financial responsibility: Payment is expected at the time of service. This includes co-pays, coinsurance, and deductibles. For your convenience we accept cash, check, or credit cards. Please provide a copy of your insurance card at each visit. It is our policy not to extend professional courtesy discounts. For our self pay patients (patients who have no insurance coverage), we offer a 35% discount for professional services paid in full on the date of service. This does not apply to co-pays, co-insurance, deductibles, non-covered services, and medical supplies. For our self pay patients (patients who have no insurance coverage), we offer a 35% discount for hospital services paid in full within 30 days of discharge. This does not apply to co-pays, co-insurance, deductibles, non-covered services, and medical supplies. You may be charged a $25 no-show fee for any appointments missed, not cancelled/rescheduled with a 24 hour notice. Multiple no-shows/cancellations may result in a discharge from practice. Old balances on your account must be paid in full prior to receiving additional services. Accounts may be turned over to a collection agency if past due 60 days or more. A service charge of $30.00 will be added for returned checks, A service charge of $10.00 will be added for co-payments not received on the date of service.. Patients are legally responsible for all collection costs involved with the collection of this account including court cost, reasonable attorney fees, and all other expenses incurred with collection proceedings on any unpaid balance. A parent-or legal guardian must accompany patients who are minors, The accompanying adult is responsible for payment of the account. We appreciate the opportunity to participate in your family s healthcare. If you have any questions regarding this policy, please let us know. I have read, understand, and agree to the above financial policy. I understand that charges not covered by my insurance company, as well as applicable co-pays and deductibles are my responsibility. Printed Name Signature Date