Patient Registration

Please correct the errors described below.

Thank you for scheduling an appointment at Adobe Gastroenterology.

*In order to limit the number of patients in our office we ask you arrive no more than 10 MINUTES prior to your scheduled appointment time*

PATIENT REGISTRATION

Employment Status

Insurance Information

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    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    PAST HISTORY

    SURGICAL HISTORY

    Have you had any surgery? (Type of operation and approximate date)

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    In the past 5 years have you had any of the following?

    Family History:

    Do you know of any relative who has or had any of the following cancers or diseases?

    Cancer History

    Social History

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    PERSONAL HISTORY

    REVIEW OF SYSTEM

    MEDICATION HISTORY

    (If yes, list allergies below and type of reaction)

    Add Additional Allergies

    Shell fish/seafood allergy Allergy to dye in CT scan and other imaging studies

    CONSENT FOR TREATMENT

    MD. I am aware if my primary physician is unavailable, I will be treated by another physician providing coverage for the Adobe Gastroenterology, PC physicians.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    PAYMENT POLICIES / INSURANCE / INSURANCE RELEASE

    It is my responsibility to pay the doctor for his services. My co-payment is due when services are rendered. For No Show appointments or same-day cancellations, a charge of $50.00 will be applied. A 24-hour notice is required. I understand this office will file insurance claims for all Medicare services, all contracted private insurance carriers, and all surgical services. I authorize the release of medical information for my insurance claims or legal purposes and authorize payment of insurance benefits to Adobe Gastroenterology, PC or Adobe Surgery Center, PC. I authorize my physician at Adobe Gastroenterology, PC to obtain my medical records and lab results from other facilities I have visited, as they deem necessary. I understand that I am personally responsible for referrals from my PCP and all charges not covered by insurance. If collection proceedings are required, I agree to pay all collection and legal fees incurred by Adobe Gastroenterology and Adobe Surgery Center.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

    FINANCIAL POLICY

    BECOME FAMILIAR WITH YOUR INSURANCE BENEFITS

    Please contact your insurance company to inquire about your insurance benefits. Your insurance company, without notice, may change your plan benefits. For example, upon renewal of many contracts, there are new deductibles, or the amount of an existing deductible may increase. Also, co-insurance and co-payment amounts may change at the start of a new benefit year. Please note that it is your responsibility to notify us of any changes in benefits and/or coverage. The quote you receive from our practice is an estimate only and other procedures may be necessary at the date of your appointment that may not have been included in the estimate. It is your responsibility to know your insurance benefits. Please contact your insurance company with benefit questions and all financial responsibilities prior to your procedure and office visit. Your insurance may require separate patient responsibility for office consults and procedures. Please be advised final patient out-of-pocket cost is determined by your insurance. In the event that your payment exceeds the final insurance determined amount, you will receive a refund for the overpayment.

    By following these steps, you will be aware of any cost that may be your responsibility after your insurance company processes your claims.

    When having a procedure, two separate charges will be billed to your insurance. A claim from Adobe Gastroenterology, PC. for the physician performing the procedure and a claim for Adobe Surgery Center, PC. for the facility charge.

    If any biopsies are collected during your procedure there will be an additional claim filed by Adobe Pathology or Tucson Pathology Associates depending on your insurance coverage.

    SELF-PAY PATIENTS

    Possible Additional Costs:

    • If a second procedure is deemed necessary by the physician after preliminary payment has been made.
    • If any pathology is required. (there will be an additional bill from Adobe Pathology or Tucson Pathology Associates).

    If you should have any further questions or need any additional information after speaking with your insurance, please contact us at 520-721-2728.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    OPTIONAL

    Authorize Adobe Gastroenterology, P.C. to give copies of my medical records to Adobe Clinical Research, LLC. I am interested in learning about clinical trials that may be helpful to my medical conditions.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    HIPAA Notice of Privacy Practices

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, HOW YOU CAN GET ACCESS TO THIS INFORMATION, YOUR RIGHTS CONCERNING YOUR HEALTH INFORMATION AND OUR RESPONSIBILITIES TO PROTECT YOUR HEALTH INFORMATION. PLEASE REVIEW IT CAREFULLY.

    This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

    Uses and Disclosures of Protected Health Information

    Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

    Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you, or your protected health information may be provided to a physician to whom you have been referred or seek counsel from, to ensure that physician has the necessary information to diagnose or treat you.

    Treatment and office visits in our facility will require that you be called by name in the reception area. You will be asked personal and medical history questions by medical personnel to ensure safe and appropriate care in our surgery center. You may share a pre- or post-op area with other patients in our surgery center.

    Obtaining approval or scheduling procedures or a hospital stay may require that your relevant protected health information be disclosed to the health plan or medical facility.

    Payment: Your protected health information will be used, as needed, to obtain payment for your health care services.

    Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, medical studies, and conducting or arranging for other business activities. You may be greeted by name at our reception desk and ask to complete registration forms or sign consent for procedures. We may also call you by name in the reception area when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment or inform you of test results. We may contact you by telephone, E-mail, Postal Service or other forms of delivery services, as your doctor deems necessary.

    Research: We may use and disclose medical information about our patients for research purposes, subject to the confidentiality provisions of state and federal law. Occasionally, researchers contact patients regarding their interest in participating in certain research studies. Enrollment in those studies can only occur after you have been informed about the study, had an opportunity to ask questions, and indicated your willingness to participate by signing a consent form.

    When approved through a special review process, other studies may be performed using your medical information without requiring your consent. These studies will not affect your treatment or welfare, and your medical information will continue to be protected. For example, a research study may involve a chart review to compare the outcomes of patients who received different types of treatment.

    We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Coroners, Funeral Directors, and Organ Donation; Research; Criminal Activity and National Security; Workers’ Compensation; Inmates, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

    Telephone calls to Adobe Gastroenterology/Surgery Center, P.C., may be monitored or recorded randomly, by management, for quality assurance or training purposes only.

    Other Permitted and Required Uses and Disclosures: Will Be Made Only with Your Consent, Authorization or opportunity to object unless required by law.

    Right to Request Restriction of PHI: If you pay in full out of pocket for your treatment, you can instruct us not to share information about your treatment with your health plan; if the request is not required by law. Effective March 26, 2013, The Omnibus Rule restricts the provider’s refusal of an individual’s request not to disclose PHI.

    Your Rights Regarding Your Health Information

    You have the right to inspect and copy your protected health information. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You must submit your request for medical records in writing to your Doctor.

    You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request, in writing, must state the specific restriction requested and to whom you want the restriction to apply. (Please ask the receptionist for a form.)

    Your physician is not required to agree to a restriction that you may request, unless you have requested a restriction on information disclosed to a health plan when you have covered the entire cost of service. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

    You also have the right to request, in writing, to receive confidential communications from us by alternative means or at an alternative location.

    You may have the right to ask your physician to amend your protected health information. If you believe your medical record is incorrect or incomplete, you may request to amend your records through the use of an authorized amendment form. The original form must be placed into your medical file at this practice. You may request an amendment form from this office. Your request must be made in writing and submitted to your doctor at Adobe Gastroenterology, 2585 N. Wyatt Drive, Tucson, AZ 85712. The original information will also be retained in your file.

    You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

    We reserve the right to change the terms of this notice. You then have the right to object or withdraw as provided in this notice.

    Breach Notification Requirements: It is presumed that any acquisition, access, use or disclosure of PHI not permitted under HIPAA regulations is a breach. We are required to complete a risk assessment, and if necessary, inform HHS and take any other steps required by law. You will be notified of the situation and any steps you should take to protect yourself against harm due to the breach.

    Right to file a complaint: If you believe your privacy rights have been violated, you may file a complaint with us by notifying our HIPAA Compliance Officer. We will not retaliate against you for filing a complaint.

    This notice was published and becomes effective on/or before July 1, 2013.

    We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. You may ask our office for a copy of this Notice at any time. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at (520) 721-2728.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    Your information will be encrypted.

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