Northern Virginia Gastrointestinal Associates, LTD. /Advanced Digestive Care, LLC.

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Primary Medical Insurance Carrier

If Self Pay (Please write "None" )
If Self Pay (Please write "None" )

Tricare Beneficiaries must provide Sponsor's SS# for claims

Secondary Medical Insurance Carrier

Tricare Beneficiaries must provide Sponsor's SS# for claims

Write none If you decline a release of records, This authorization can be revoked at anytime if requested in writing:

Assignment of Benefits: I hereby authorize payment directly to the physician of Northern Virginia Gastrointestinal Associates, LTD/ Advanced Digestive Care, LLC. of any surgical or medical benefits, If any, otherwise payable to me for services. I understand that I am responsible for all non-covered services and I am also responsible for any fees associated with attempting to collect on unpaid balances.

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My Health History

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    Social History

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    PRACTICE POLICY: General Office Procedures and Financial Procedures

    Appointments: When scheduling appointments, it is our intent and wish that you are seen as soon as possible, given the restraints of our mutual schedules. Please be aware that we are mindful of emergencies that may arise or the urgency in which you may need to be seen. To schedule an appointment, please call our office Monday-Thursday, 9-5 PM and Friday 9-4 PM at 703-876-0437. Failure to cancel an Office Visit will result in a No call/ No Show fee of $50.00 and failure to cancel a procedure within 7 business days will result in a No can/ No Show Procedure/late cancellation fee of $350.00, that is not billable to insurance and must be paid prior to rescheduling your Appointment! Procedure.

    Prescriptions: On calling the practice, choose the option for prescription refills. Prescription calls to patients and the pharmacy will be handled within 2 business days (48) hours. You must have had an office visit within one year in order to receive any refills.

    Medical Records/Forms: Your written and signed request will be processed within two weeks of our receipt of the request. Requests can be faxed to our office at 703-876-0722, sent by USPS or given in person. The fees associated with Electronic Records is a $20 search fee, plus $0.37 for the first 50 pages and $0.18 cents per page thereafter; for Paper Records, there is $20 search fee, plus $0.50 for the first 50 pages and $0.25 cents per page thereafter. Please keep a personal file of any records that you give us. We do not provide copies of other doctor's records that are in our possession. Each healthcare provider is responsible for providing those records directly to you. Additionally, there is a $50.00 fee for completing disability forms and Insurance applications, a $25.00 fee for FMLA Forms and any dictated letters or requests, etc.

    Referrals and Procedure Precertification: Please have necessary referrals and insurance forms with you at the time of your office visit if required by your insurance. This applies to HMO and managed care plans. It is your responsibility to obtain the required paperwork prior to your office visit with your medical provider. If you are unsure If you are required to have a referral, you should call your insurance and/or your primary care doctor. Should your medical provider decide it is necessary to undergo a procedure, our office will make sure precertification is complete. THIS PROCESS IS NOT THE SAME AS GETTING A REFERRAL Our office does the best we can to follow each plan's requirement s, but due to the number of different insurance plans available today it is impossible for us to know the requirements of every single plan, so it is in the patient's best interest to check eligibility at least 7 days prior to any procedure. If the service being requested by your doctor is medically necessary, but not payable by your insurance, the patient may choose to pay out of pocket and those fees will be provided to the patient in writing before the procedure.

    Insurance and Payments: For those patients covered by participating plans, we will file claims to those plans for services we provide to you. Due to significant costs incurred by multiple submiSSions, our office reserves the right to re-submit medical claims to insurance carriers only TWO TIMES; if insurance does not pay after the second attempt and there are not submission errors, the patient will then be liable for the entire balance. Please be advised that we are bound by our contracts with each insurance carrier to collect co-pays, co-insurance, deductibles, and other monies due by the patient to our office at the time of service. In order for our office to ensure care is available to all patients seeking our services, we require that payment of uncovered services is made in full at the time of the visit. Payments can be made In the form of cash, check, MasterCard, Visa, Discover, and American Express. If your check is returned by the bank for any reason there will be a $50 fee assessed to your account that is not covered by insurance. We ask that you adhere to these policies as we are not a lending institution and do not have the resources to extend credit to patients. When payment arrangements must be made, those arrangements must be acceptable to both parties.

    Screening VS. Diagnostic Exams: You may believe that you are due for a preventative (screening service), but there may be personal or family history that disallows billing as a preventative service. Please check with your individual plan for your benefits and eligibility at least 7 days prior to your scheduled procedure. The billing office must follow Federal Guidelines when filing medical insurance claims and can help guide you through the process of medical claims and is happy to answer any questions you may have.

    Updating Insurance Information: It is the patient's responsibility to provide our office AND the facility with any updated insurance information PRIOR to any treatment. Facilities and offices DO NOT share information. The patient must provide documentation to all parties billing on a patient's behalf. Failure to do so can result in claims being denied and patient being held liable for payment.

    Account Balances/Collections: All Payments are due upon receipt of 1st statement. Additionally, any balance that remains unpaid without acceptable arrangements after 90 days will have the potential to be turned over to a collection agency, which can affect your credit report. If that occurs, the patient will be responsible to pay all balances owed to the collection agency and any fees and interest to Northern Virginia Gastrointestinal Associates LTD. /Advanced Digestive Care LLC as allowed by Virginia law, BEFORE any additional visits will be made with a medical provider.
    I have read and understand the above policies.

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

    I consent to have the following diagnostic examination performed by Dr. Goldstein, Dr. Prosky, or Or. Vemana.

    Please read the following statements: I understand that there may be risks associated with any endoscopic examination. Potential complications may include risk of drug reaction, localized swelling of the arm following intravenous medication, or bleeding. Serious complications such as bleeding or perforation of the intestinal wall can occur but are usually associated with a polypectomy or dilation. Excessive bleeding may require blood transfusions and perforation may require surgical intervention.

    • I understand that these procedures are not always accurate and that diagnostic errors can occur.
    • If any unforeseen condition arises during this procedure, I authorize Dr. Goldstein, Dr. Prosky, or Dr. Vemana to do whatever is deemed medically necessary.
    • Please note that there is a professional fee, a facility fee, and anesthesia fee, and possibly a pathology fee associated with this procedure. You will receive separate bills for each fee. If you have questions about your out of pocket expense you should contact your insurance carrier.

    Procedure Cancellation/Rescheduling: Policy: (Please initial to acknowledge the statements below.)

    Northern Virginia Gastrointestinal Associates, a division of Advanced Digestive care, requires 7 business days' notice prior to canceling or rescheduling your procedure. There will be a $350 fee assessed for failing to appear for your scheduled procedure or for not providing 7 business days' notice to cancel/reschedule.

    Transportation Policy: (Please initial to acknowledge the statements below.)

    • You MUST make arrangements for an adult (18+) to drive you home.
    • YOU MAY NOT TAKE A TAXI, UBER, or LYFT unless accompanied by an adult (18+). The facility you are scheduled with has reserved the right to confirm your transportation prior to your procedure.
    • If you do not have a confirmed ride, your procedure will be cancelled.
    • If your procedure is scheduled at Woodburn Endoscopy Center for 2:00 PM or later, YOUR RIDE MUST REPORT TO THE CENTER DURING YOUR CHECK IN PROCESS AND REMAIN AT THE FACILITY.
    • You should NOT operate any heavy machinery for at least 12 hours after receiving medication for sedation.


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

    Advance Beneficiary Notice of Noncoverage (ABN)

    NOTE: If Medicare doesn't pay for: D. Colonoscopy below, you may have to pay.
    Medicare does not pay for everything. even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. Colonoscopy below.

    D. Colonoscopy

    E. Reason Medicare May Not Pay:

    F. Estimated Cost

    G0121 or G0105

    Screening coverage for Colonoscopies is only provided once every 10 years, if the patient is not in a higher risk category



    • Read this notice, so you can make an informed decision about your care.
    • Ask us any questions that you may have after you finish reading
    • Choose an option below about whether to receive the D. COLONOSCOPY listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

    H. Additional Information:
    This notice: gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing. call 1-800-MEDICARE (1-8O00-633-4227/TTY, 1-871-486-2048).

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

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