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.

Add file

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.

Add file

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.

Add file

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, we aim to see you as soon as possible, while accommodating scheduling constraints. We understand that emergencies may arise and will do our best to address urgent needs. Please note that arriving more than 10 minutes late may require rescheduling your appointment, as we strive to keep our schedule running smoothly. To schedule an appointment, please call our office Monday–Thursday, 9 AM–5 PM, and Friday 9 AM–4 PM at 703-876-0437.

Same day cancellations and failure to cancel appointments will result in a No Call/No Show fee of $50. Failure to cancel a procedure within 7 business days will result in a No Call/No Show Procedure/Late Cancellation fee of $350. These fees are not billable to insurance and must be paid prior to rescheduling your appointment or 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 include a $20 search fee, plus $0.18 per page for the first 50 pages, and $0.37 per page for any pages thereafter. For Paper Records, there is a $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 doctors’ 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, 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 pre-certification is complete. THIS PROCESS IS NOT THE SAME AS GETTING A REFERRAL. Our office does our best to adhere to each insurance company’s requirements, 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 urgent but not payable by your insurance, we will notify you, and the services will be provided to the patient with financing options made available.

Insurance and Payments: For patients covered by participating insurance plans, we will file claims for services provided. However, due to the costs associated with multiple submissions, our office will only re-submit claims twice. If payment is not received after the second attempt and there are no submission errors, the patient will be responsible for the remaining balance. As required by our contracts with insurance carriers, we collect co-pays, co-insurance, deductibles, and other patient financial responsibilities at the time of service. To ensure continued access to care for all patients, payment for uncovered services must be made in full at the time of the visit. Accepted payment methods include cash, check, MasterCard, Visa, and Discover. Please note that returned checks will incur a $50 fee, which is not covered by insurance.

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 patients being held liable for payment.

Account Balances/Collections: Any payments that remain unpaid within 30 days of the first statement provided to the responsible party will be subject to a $5.00 fee per month. Additionally, any balance that remains unpaid without acceptable arrangements after 90 days will have the potential to be turned over to a collection agency. 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:

Your information will be encrypted.