PATIENT REGISTRATION FORMS

Last Name:

First Name:

SS#:

Date of Birth:

Age:

Sex:

M F

Email:

Street Address:

APT#:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Ext#:

Cell:

Marital Status:

Employment Status:

Emergency Contact Name:

Phone:

Relationship:

Race:

White Black or African American Native Hawaiian or Other Pacific Islander America Indian or Alaska Native Asian Decline Response

Ethnicity:

Latino/Hispanic Non Latino/Non Hispanic Decline Response

Please attach a copy or image of a valid form or identification (Driver's License, ID Card, Passport, etc.)

Add file

Please upload a file

Preferred Language:

English Spanish Other

If you selected Other, please specify:

If you have any records or reports that you’d like to have your provider review, you may attach them here.

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Please upload a file

Primary Medical Insurance Carrier

Self Pay (No Insurance)

Please attach an image copy of your insurance cards (front and back)

Add file

Please upload a file

Name of Primary Insurance

Policy Holder:

Policyholder's Date of Birth:

Relationship to Policyholder:

Policyholder's Sex:

Male Female

Work #:

Home #:

Cell #:

Tricare Beneficiaries must provide Sponsor's SS# for claims

Secondary Medical Insurance Carrier

No secondary insurance

Please attach an image copy of your insurance cards (front and back)

Add file

Please upload a file

Name of Secondary Insurance

Policy Holder:

Policyholder's Date of Birth:

Relationship to Policyholder:

Policyholder's Sex:

Male Female

Work #:

Home #:

Cell #:

Tricare Beneficiaries must provide Sponsor's SS# for claims

Are you a New or Returning patient?

I am New I am Returning

Consent for treatment: By signing, this form I consent to treatment by the Medical providers of Northern Virginia Gastrointestinal Associates / Advanced Digestive Care, LLC. I understand that the provider may order diagnostic testing and/or minor surgical procedures I further acknowledge that neither the provider nor the staff can or has made any guarantees or assurances as to the results that are obtained. Please initial to confirm your agreement with this policy.

I understand that I have certain rights about how my personal information is stored, used, or shared. A complete copy of these rights is available for my review in the office or one will be provided to me should I request it. In addition, I would like healthcare related information to be released to (please list names below). Write none If you decline a release of records, This authorization can be revoked at anytime if requested in writing:

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

Please initial here to acknowledge this HIPAA Statement:

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.

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.

Signature:

Date:

My Health History

Reason for your visit

Height

Weight

I have a Referring MD

I have a Primary MD

Referring MD:

Primary MD:

Phone Number

Fax Number

Have you ever had an Colonoscopy before?

Yes No

Date:

Location:

Dr:

Have you had a Colonoscopy with a different practice/provider since your last visit with us?

Yes No

Date:

Location:

Dr:

Have you ever had an Endoscopy before?

Yes No

Date:

Location:

Dr:

Have you had a Endoscopy with a different practice/provider since your last visit with us?

Yes No

Date:

Location:

Dr:

Do you have any allergies to medications?

Yes No

List Medication Allergies:

List all of your Current Medications and Dosage (mg)

If you have a copy of your Medication List, you may upload it here.

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Please upload a file

I currently do not take any Medications

Add another

Are you vaccinated for COVID-19?

Yes No

Please provide a copy of COVID-19 Vaccination Card:

Add file

Please upload a file

Please List your Local Pharmacy·

City:

Phone #:

Mail order Pharmacy:

Add another

Has there been a change/update in your Surgical History since your last appointment with our practice?

Yes No I do not have any surgical history

If you have a copy of your surgical history, you may upload it here.

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Please upload a file

I do not have any Surgical History

Add another

Social History

Used Tobacco in the past?

Y N

Quit Date:

Current Tobacco Use?

Y N

Packs per Day:

Do you vape?

Y N

What kind of vape device do you use?

Can include devices like e-cigarettes, e-hookahs, mods, vape pens, vapes, tank systems, etc.

Drink Alcohol?

Y N

Glasses Weekly:

Drink Caffeine?

Y N

Cups Daily:

Exercise?

Y N

How often:

Travel Outside of US in last 6 months?

Dates:

Present Occupation:

Has there been a change/update in your Medical History since your last appointment with our practice?

Yes No

If you selected Diabetes, please specify what type:

If you selected Cancer, please specify what type:

If you selected Hepatitis, please specify what type:

If you selected Other, please specify:

Date of last PPD/TB Test:

Result:

If you selected Diabetes, please specify what type:

If you selected Cancer, please specify what type:

If you selected Hepatitis, please specify what type:

If you selected Other, please specify:

Date oflast PPD/TB Test:

Result:

Are you experiencing any signs or symptoms you would like to discuss at your appointment?

Yes No

If you selected Other, please specify:

Has there been a change/update in your Family History since your last appointment with us?

Yes No

If you selected Colon Cancer, which family members:

Age:

If you selected Colon Polyps, which family members:

Age:

If you selected Ulcerative Colitis, which family members:

Age:

If you selected Crohn's, which family members:

Age:

If you selected Stomach Cancer, which family members:

Age:

If you selected Gallbladder Disease, which family members:

Age:

If you selected Barrett's Esophagus, which family members:

Age:

If you selected Esophageal Cancer, which family members:

Age:

If you selected Heart Disease, which family members:

Age:

If you selected Liver Disease, which family members:

Age:

If you selected Other, which family members:

Age:

If you selected Diabetes, which family members:

Age:

If you selected Other, please specify:

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.

Signature:

Date:

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