Patient Forms

Patient History

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Gastroenterology

Acknowledgement of Receipt of Notice of Privacy Practices

To Our Patients:

In accordance with Federal Law on the Patient Privacy, please read the following:

This statement is to advise you that our office has a Privacy Policy (complete policy in waiting room) in place to protect your medical information. In brief, our policy states that our office will keep your
medical record information confidential and will use it only for treatment, payment and healthcare operations. The office may release information to other doctors during emergencies, or cases of
neglect and abuse. Our policy identifies your rights to access your records, request restrictions on who can see and be informed of your medical information. In short, to keep your communications
with this office confidential.

Our Privacy Policy can be reviewed in its entirety, or you may request 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.

You have my permission to release my medical information to the following: (please check and list name and phone number)

Patient Information

I hereby authorize my insurance benefits to be paid directly to the physician and I understand that I am financially responsible for all non-covered charges. Payment is due and payable at the time services are rendered. I understand that my credit card is on file and that any remaining balance I owe may be charged to my credit card. I also authorize my physician to release any information to my insurance company for the processing of my insurance claims. HMO patients who do not have prior authorization to see Dr. Onuma or Dr. Lee will be financially responsible for any charges incurred.

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.

Peninsula Gastrointestinal Specialists, Inc

Credit Card Billing Authorization Form

Peninsula Gastrointestinal Specialists, Inc. is offering a secure and convenient method of payment for the portion of services that your insurance does not cover.

I authorize the above practice to apply charges to my payment card for all amounts owed to the practice.

I authorize Peninsula Gastrointestinal Specialists, Inc. to charge my credit/debit payment card as payment for any balance put into the "patient responsibility" after my insurance plan has paid its portion.

Multiple attempts will be made to contact you to discuss any remaining balance, and only balances past 90 days will be charged to your card.