Pediatric Patient Demographic Information

Texas Midwest Gastroenterology Center, PA

Please correct the errors described below.

PARENT DEMOGRAPHIC INFORMATION

PARENT / GUARDIAN INFORMATION

INSURANCE INFORMATION

PRIMARY CARE AND REFERRING PHYSICIAN INFORMATION

AUTHORIZATION FOR VOICEMAIL / EMAIL REGARDING HEALTH INFORMATION

I further understand that this permission to communicate personal health information will remain in effect until I request, in writing, to have this option of communication terminated

ASSIGNMENT AND AUTHORIZATION OF BENEFITS

I certify the above information is correct. I consent for the patient to be treated by the staff and providers of TMGC, PA,and its affiliates. I hereby give authorization for payment of insurance benefits to be made directly to TMGC, PA for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection and responsible attorney fees. I hereby authorize this healthcare provider to release all information necessary to secure payment of benefits. I further agree that a photocopy of this agreement is as valid as the original.

TMGC, PA frequently utilizes mid-level practitioners including Nurse Practitioners and Physician Assistants to assist in the delivery of medical care. Mid-level practitioners are under the supervision of a physician and can diagnose, treat, and monitor common acute and chronic diseases. I hereby consent to the services of a mid-level practitioner for my healthcare needs. I understand that at any time I can refuse to see the mid-level practitioner and request to see a Physician.

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.

Financial Policy

Texas Midwest Gastroenterology Center, PA (TMGC, PA) has a responsibility to provide quality healthcare services to patients. In the interest of maintaining a good doctor-patient relationship and continuing the delivery of quality healthcare, it is our hope that you will take responsibility for your financial obligation to our practice. Following are general policies we have established for our patients, which we believe allow the flexibility that some patients need. We encourage you to discuss financial options with our office personnel. Discussion of these issues early on in your treatment process will prevent most concerns or misunderstandings.

  1. Insurance – As a courtesy to our patients, we will file claims on all visits and procedures, whether they are delivered in our office or the hospital. When we file a claim on your behalf, it is with the understanding that benefits will be assigned to TMGC, PA (that is, the insurance company will pay TMGC, PA directly). You are responsible for payment of all deductibles, co-insurance and non-covered services. Please remember insurance coverage is a contract between the patient and the insurance company. The ultimate responsibility for understanding your insurance benefits and for payment to your doctor rests with you.
  2. Referrals – You are required to 1) know whether or not your insurance requires a referral; and 2) obtain that referral before you are scheduled to see our providers. Our office will be happy to assist you in determining the status of our providers on your insurance plan; however, this is not a guarantee of coverage. You should take the time to call your insurance company to ask specifically about your covered benefits. Referrals typically have an expiration date and a limited number of visits so you should be careful to monitor the dates and visits.
  3. No Insurance – Patients who do not have insurance are expected to pay for all services rendered. We will request a payment for outpatient procedures in advance of having the procedure performed.
  4. Returned Checks – Your account will be charged a $50 fee for each returned check. In addition, you will be asked to bring cash to our office to cover the returned check and the fee.
  5. Past Due Accounts – Patients who have not made an effort to make payment arrangements or have not expressed an interest in meeting their financial obligation to us may be turned over to a collection agency. Patients who have allowed their account to be turned over to an agency will be expected to satisfy their financial obligation to us before being seen by our providers.
  6. Out of Network Services – TMGC, PA and Texas Midwest Endoscopy Center does not make any guarantees that any laboratory, anesthesiology or other professional services are in-network providers for your contracted insurance plan. You are responsible for any professional charges in conjunction with the services you receive at the facility whether these services are considered in or out of network with your insurance plan.
  7. Non-Covered Services – You have scheduled a visit with one of our physicians or nurse practitioners that the physician believes to be relevant to evaluate, monitor and protect your health; however, Medicare and certain other insurance companies will only pay for services that they determine to be “reasonable and necessary.” If Medicare or another insurance company determines that your visit with our physician or nurse practitioner is not “reasonable and necessary,” then they will deny payment for that service. Sometimes insurance companies will not cover an office visit prior to a procedure when the patient comes to the doctor with no symptoms and is requesting a screening procedure. Denial of payment by your insurance company does not mean that you do not need to visit with the physician or nurse practitioner beforehand.

An office visit prior to the performance of any procedure is necessary in order to evaluate the patient’s general health. In addition, this will ensure that the patient is well informed about any recommended procedure and allow the opportunity to obtain Informed Consent for the procedure. We are required to inform you that your insurance company may not cover the office visit and that you will be responsible for payment.

Patient Statement

I have been informed of Texas Midwest Gastroenterology Center’s financial policy and agree to its terms. I have been notified that Medicare and other insurance companies may deny payment for my initial office visit for the reasons stated above. If Medicare or my insurance company denies payment for any services rendered, I agree to be personally and fully responsible for payment.

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.

General Consent to Use and Disclosure of Protected Health Information

understand that Texas Midwest Gastroenterology Center, PA creates and maintains medical and related records that include personal healthcare information, including the patient’s health records, symptoms, demographic information, diagnoses, examination and test results, treatment, and any plans for future care or treatment. This is the patient’s “protected health information”.

I understand and consent to the use and disclosure of the patient’s Health Information by Texas Midwest Gastroenterology Center, PA for the following purposes:

  • Treatment: This includes the provision, coordination, or supervision of the patient’s healthcare and related services, including the coordination or management of the patient’s care and consultation between healthcare professionals related to treatment, or the patient’s referral to another healthcare professional.
  • Payment for healthcare services provided to the patient: This includes actions undertaken by a health plan to decide coverage or the provision of benefits to the patient, by my Provider or a health plan to obtain or provide compensation for my care, or otherwise related to the patient.
  • Provider’s internal operations: This includes quality assessment and improvement activities; reviewing provider performance and training; activities relating to health insurance and benefits; conducting or arranging for medical review, legal services, and audits; business planning and development; and business management and general administrative activities including customer service, resolution of internal grievances, due diligence, and creating de-identified healthcare information.

I understand and agree that:

  • I have the right to review Texas Midwest Gastroenterology Center’s Notice of Privacy Practices for Protected Health Information, which provides a much more detailed description of information uses and disclosures, prior to signing this Consent.
  • Texas Midwest Gastroenterology Center, PA may change or modify its Notice of Privacy Practices for Protected Health Information at any time, and I have the right to obtain a revised Notice of Privacy Practices by accessing www. texasmidwestgastro.com website or requesting a revised copy in the office.
  • I have the right to request restrictions as to how the patient’s Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations. I understand and agree that the Provider is not required to agree to any restrictions that I may request, but if the Provider agrees, it will be bound by that restriction.
  • I have the right to revoke this Consent by notifying the Provider in writing that I revoke this Consent unless the Provider has used or disclosed my Health Information in reliance on this Consent.

YOU MAY DISCLOSE MY HEALTHCARE INFORMATION TO THE FOLLOWING INDIVIDUALS OR ENTITIES (PLEASE PRINT):

Add Additional Name

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.

Personal History

5. SURGICAL HISTORY (Check all that apply including age and date of procedure or hospitalization).

9. LABORATORY TESTS (Please list when and where) If none, type N/A

10. IMAGING (Please list when and where) If none, type N/A

11. CURRENT DIETS

12. BIRTH HISTORY

13. SYSTEMS REVIEW Does the patient currently have or has recently experienced any of the following? Note, if a family member is experiencing or has any of the following. (Family members include parents, siblings, grandparents)

EYES

GASTROINTESTINAL, continued

HENT

GENITOURINARY

CARDIOVASCULAR

SKIN

RESPIRATORY

NEUROLOGIC

MUSCULOSKELETAL

GASTROINTESTINAL

ENDOCRINE

PSYCHIATRIC

LYMPHATIC/HEMATOLOGY

ALLERGY / IMMUNOLOGY

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.

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