Procurement & Policies (Medicare)

Please correct the errors described below.

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

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.
  • If your procedure is scheduled at McLean Surgical Center, your ride MUST REMAIN AT THE SURGICAL CENTER DURING YOUR PROCEDURE. THIS POLICY IS ENFORCED BY THE FACILITY AS WELL.
  • You should NOT operate any heavy machinery for at least 12 hours after receiving medication for sedation.

**PLEASE NOTIFY OUR OFFICE IF YOUR INSURANCE PLAN CHANGES BEFORE THE DATE OF YOUR PROCEDURE**

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.

Notifier: Advanced Digestive Care, LLC

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.

$220

WHAT YOU NEED TO DO NOW:

  • 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.

G. OPTIONS: Check only one box. We cannot choose a box for you.

listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on aMedicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you minus co-pays and/ or deductible
listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare will pay.

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 (1-800-633-4227 /TTY: 1-877-486-2048).

Signing below means that you have received and understand this notice. You also receive a copy.

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.

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov

According to the Paperwork Reduction Act of 1995, no persons :u:e required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Repons Clearance Officer, Baltimore, 1faryland 21244-1850.

Your information will be encrypted.

Loading...