Lowcountry Gastroenterology Associates
I hereby authorize Lowcountry Gastroenterology Assoc. PA to discuss any matters related to my medical treatment and/or payment for services rendered with the following persons:
**We leave messages (i.e. appointment reminders, biopsy results, etc.) on the answering machine or voicemail of the telephone numbers given by you. Unless otherwise specified, we also may leave messages with your spouse. If you do NOT want these messages left, please indicate and tell the office staff member at the reception window.**
I hereby authorize for my health information to be included in the Community Health Exchange program. (EHX)
(This authorization allows your records at our practice to be shared with any of your Roper or East Cooper doctors.)
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.
I hereby consent treatment by the providers and/or associated of Lowcountry Gastroenterology Associates P.A.
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.
I hereby acknowledge that I have reviewed a copy of Lowcountry Gastroenterology Associates. PA's Notice of Privacy Policies and Practices. These policies are in the white notebook in the waiting area of our office.
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.
I authorize for Lowcountry Gastroenterology to allow me to participate in E-SCRIBE MEDICATIONS. This allows us to electronically send your prescriptions.
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.
**Please fill out all of your medications currently**
PLEASE LIST ALL MEDICATION & FOOD ALLERGIES: (ie: eggs) & REACTIONS
Welcome to LCGI. In order to be able to deliver the quality of care that you are accustomed to, we have established our financial policies. The following is a list of the guidelines that are necessary in order to continue to provide high quality care and make your visit as pleasant as possible.
Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your charges. If you have any questions regarding our financial policy, please contact our billing department. (843) 884-5200
I have read and have full understanding of the financial policy of lowcountry Gastroenterology.
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.
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.
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.
Your information will be encrypted.