New Patient and Existing Patient Form

IN CASE OF EMERGENCY

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.**

AUTHORIZATION

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.

MEDICATION LIST

**Please fill out all of your medications currently**

PLEASE LIST ALL MEDICATION & FOOD ALLERGIES: (ie: eggs) & REACTIONS

LOWCOUNTRY GASTROENTEROLOGY FINANCIAL POLICY

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.

1. We ask that you present you insurance card at each visit. It is your responsibility to provide us with the correct information to bill your insurance.
2. If you have a change of address phone number, or employer, please notify the receptionist.
3. We will collect your deductible, co-pay, or charge for non-covered services at the time of your visit. If you have a balance after an insurance payment from a previous service, we will also ask for payment. We accept, cash, check and all major credit cards.
4. If we do not participate with your insurance company, you will be expected to make a payment in full at the time services are rendered.
5. If your insurance denies our charges or does not pay us in a timely manner, or if your account becomes delinquent we reserve the right to refer your account to a collection agency and to be reported to one or more credit bureau(s).
6. MEDICARE PATIENTS: We are participating providers with Medicare and will bill Medicare for all of your covered charges. If you have supplemental insurance, we will also bill that for you. We then will bill you once the supplemental has been processed.
7. COMMERCIAL INSURANCE PATIENTS: We will bill your insurance for you; however your co-pays will be collected at the time of the service, NO EXCEPTIONS. If your insurance requires an authorization to see a specialist. it will be your responsibility to obtain that authorization.
8. SELF PAY PATIENTS: Patients with no insurance will be expected to pay at the time of service. If you are unable to pay in full; you must call our billing department PRIOR to seeing the physician to make payment arrangements.
9. NO SHOW OR MISSED APPOINTMENTS: When an appointment is scheduled with the physician, time is specifically allotted for you. When an appointment is not cancelled in advance, and the patient "NO SHOWS" another patient is unable to be moved into that slot. We understand that there may be times when you are unable to keep your appointment, but we ask for you to give us a courtesy call to cancel your appointment. If TWO appointments are missed without cancellation, you will be charged a $25.00 fee. If THREE appointments are missed, you will be dismissed from the practice for non-compliance.
10. Your insurance is a contract between you, your employer and the insurance company. WE ARE NOT A PARTY TO THAT CONTRACT. It is very important that you understand the provisions of your policy. We cannot guarantee payments of all claims. If your insurance company pays only a portion of the bill of rejects your claim, any contact or explanation should be made to you, there policy holder. Reduction or rejection of your claim by your insurance does not relieve you of your financial obligation.

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.

• INDIVIDUAL'S FINANCIAL RESPONSIBILITY: I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service. Co-payments, co-insurance and deductibles are due at time of service. If my plan requires a referral, I must obtain it prior to my visit and not having a valid referral will result in balance billing for these services. In the event that my health plan determines a service to be "not payable", I will be responsible for the complete charge and agree to pay the costs of all services provided. If I am uninsured, I agree to pay for the medical services rendered to me at time of service.
• INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFiTS: I hereby authorize and direct payment of my medical benefits to Lowcountry Gastroenterology Assoc. on my behalf for any services fumished to me by the providers. I understand that it is my responsibility to provide lowcountry Gastroenterology Assoc. with the most current insurance information and not providing this information could result in balance billing for services rendered by Lowcountry Gastroenterology Assoc. I understand that if my insurance requires a referral for a specialist it is my responsibility to obtain the required referral prior to being seen.
• MEDICAID: I understand that if a visit is deemed a non-covered benefit or a required referral is not obtained prior to my visits with lowcountry Gastroenterology Assoc., I will be responsible for the balance not covered by my Medicaid plan.
• CREDIT CARD POLICY: In order to benefit both the patient and provider, lowcountry astroenterology Assoc. requires a signed credit card authorization form to be on file for each patient. This information will be used for your convenience to pay balances on your account not to exceed $300.00. We will contact you prior to processing and transactions that exceed $300.00 for approval. If you decline to sign, a $10.00 administrative fee will be charged for each paper statement that is sent.

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.

• NON-PAYMENT: If your account is over 90 days past due, you will receive two courtesy calls and if payment is not made within 20 days of the final call the account will be forwarded to collections and any fees associated with this status will be added to the account balance for these proceedings. Once the account is placed in collection status all payments are required prior to making any appointments.
• CANCELLATION AND MISSED APPOINTMENTS: lowcountry Gastroenterology Assoc. requires 24 hour notice for cancellations of all appointments. For missed medical appointments there will be a $25.00 fee. All procedure appointments that have not been canceled within 48 hours may be charged $100.00.

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.