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      Emergency Contact

      I, the undersigned, attest that the above information is true and complete, to the best of my ability:

      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 read and initial next to each statement.

      Permission for Treatment

      Permissions for Release of Medical Information

      Assignment of Benefits

      Payment for Services Rendered

      Referrals & Authorizations

      Cancellation Policy

      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.

      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.

      Telemedicine Consent

      Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.

      I understand there are potential risks with this technology:

      1. The video connection may not work or that it may stop working during the consultation.
      2. The video picture or information transmitted may not be clear enough to be useful for the consultation.
      3. I may be required to go to our location if it is felt that the information obtained via telemedicine was not sufficient to make a diagnosis.

      The benefits of a telemedicine consultation are:

      • You may not need to travel to the consult location.
      • You have access to a specialist through this consultation.

      Consent for Treatment. I hereby authorize to be interviewed by the physician and/or assistants to participate in my medical care through the use of telemedicine. I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.

      I acknowledge that the physician’s advice, recommendations, and/or decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of images that may result from electronic transmission.

      I hereby release Southwest Gastroenterology and its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of such videotapes, digital recording films and photographs.

      I have read this document and understand the risk and benefits of telemedicine consultation and I hereby consent to participate in the telemedicine visit under the conditions described above.


      • MAC/PC/Linux/Chromebook with camera, microphone, and speakers
      • Internet connection with at least 750kb/s download and upload speeds
      • Google, Chrome, Mozilla Firefox or Safari 11+ (latest versions)
      • Latest operating systems preferable (Windows 10 or MacOS Catalina)
      • Javascript enabled

      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.


      Personal Information


      SURGICAL (Have you had an operation?)

      Female Organs

      MEDICAL (Have you had any of the following?)




      Bring medication list or list all medications currently taking including over-the-counter medications and prescription medications, and how much of each.

      (Including Tums, Rolaids, Alka Seltzer, Maalox, Mylanta, Riopan, Digel, Gaviscon)



      Effective Date: April 14, 2003


      If you have any questions about this notice, please contact:
      Privacy Officer:
      Melanie Tsen
      911 S. Hwy 123 Bypass
      Seguin, Texas 78155
      (830) 372-9042

      This Notice tells how this Practice, its physician(s), or other health care professionals who work under contract or under the direction of our Practice and our staff, may use and disclose medical information about you. Other personnel affiliated with our practice who are authorized to have access to your medical records, are subject to this notice. In addition, this Practice, in cooperation with other healthcare facilities, providers and/or insurance carriers may share medical information with each other for treatment, payment, or health care operations described in this notice. This Notice also describes your rights and our obligations regarding the use and disclosure of this information. Additionally, this Notice applies to all your records created and/or maintained by this Practice.

      We understand that medical information about you and your health is personal. We are committed to protecting this information. Each time you visit our Practice, a record of the care and services you receive is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, plan for future care or treatment, and billing record. This record serves as a:

      • Basis for planning your care and treatment;
      • Means of communication among the many health care professionals who contribute to your care;
      • Means by which you or third-party payers (insurance) can verify that services billed were actually provided;
      • Tool for educating health professionals;
      • Source of information for public health officials; and
      • Tool for assessing and continually working to improve health care rendered

      Our Responsibilities

      This Practice shall:

      • make every effort to maintain the privacy of your health information;
      • provide you with notice of our legal requirements and privacy practices with respect to information we collect and maintain about you;
      • abide by the terms of this NOTICE OF PRIVACY PRACTICES;
      • accommodate reasonable requests you may have to communicate with you by alternative means or to different locations.

      The Reasons Why We May Use and Disclose Medical Information About You:

      Listed below are different ways we may use and disclose your medical information. Examples serve only as illustrations and do not include every possible use or disclosure.

      ❖ For Treatment

      We will use and disclose your protected health information to provide, coordinate, or manage your health care services. For example, we may share your information with other specialists to whom you are referred for treatment.

      ❖ For Payment

      We will use and disclose medical information about you so that you, your insurance company, or a third party may be billed for services. For example, we may need to disclose protected health information to a health plan (insurer) in order for your health plan to pay us for the services rendered to you. We may also tell your health plan about a treatment or procedure you are going to receive in order to obtain prior approval and to determine whether your plan will cover the expenses for the procedure

      ❖ For Health Care Operations

      We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run this Practice in an efficient manner and ensure that all patients receive quality care. For example, your medical records and health information may be used in the evaluation of health care services to determine appropriateness and quality of health care treatment. In addition, medical records are audited for documentation and billing purposes

      ❖ For Appointment Reminders

      We may use and disclose medical information in order to remind you of an appointment. For example the Practice may send you a written notice or telephone reminder that your next appointment is coming up.

      ❖ As Required by Law

      We will disclose medical information about you when required to do so by federal or Texas laws or regulations.

      ❖ For Research

      Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of patients who received one medication to those who received another medication for the same condition. All research projects are subject to a special approval process. We will ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are.

      ❖ To Avert a Serious Threat to Health or Safety

      We may use and disclose medical information about you to medical or law enforcement personnel to prevent a serious threat to your health and safety or the health and safety of the public or another person.

      For Distribution of Health Care Information and/or Marketing

      This Practice does not share patient's health information with outside firms for product marketing. We may use certain information (name, address, telephone number, dates of service, age, and gender) to send you information about the Practice's health programs, services, and growth. If you do not wish to receive this information, please write to the Practice Manager whose address is listed on the front page of this notice.

      Special Situations

      ❖ Organ and Tissue Donation

      If you have indicated in writing your desire to be an organ donor, we may release medical information to organizations that handle procurement of organs, eyes, or tissue transplantations.

      ❖ Military and Veterans

      If you are or were a member of the armed forces, we may release medical information about you as required by military or other authorities.

      ❖ Workers' Compensation

      We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

      ❖ Qualified Personnel:

      We may disclose medical information for management audit, financial audit, or program evaluation. The personnel involved in these operations may not identify you in any report, audit, or evaluation, or otherwise disclose your identify in any way

      ❖ Law Enforcement

      We may release medical information if asked by a law enforcement official or required by a court order or subpoena. We may release information if we determine that there is a probability of imminent physical injury to you or to another person, or immediate mental or emotional injury to you. [This paragraph may not apply to very specific patients who are Practice Patients under particular and specific circumstances.]

      ❖ Physician Sale of Practice

      We may use and disclose medical information about you to another physician or healthcare facility in the sale, transfer, merger, or consolidation of this physician's practice.

      ❖ Public Health Risks

      We may disclose medical information about you for public health activities. These activities generally include the following:

      • To prevent or control disease, injury, or disability;
      • To report births and deaths;
      • To report child abuse or neglect;
      • To report reactions to medications or problems with products;
      • To notify people of recalls of products they may be using;
      • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

      To notify the appropriate governmental authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. All such disclosures will be made in accordance with the requirements of Texas and federal laws and regulations

      ❖ Health Oversight Activities

      We may disclose medical information to a health oversight agency for specific activities. Health oversight agencies are authorized by law to oversee the health care system. For example, an oversight agency may perform audits, investigations, inspections, and evaluations for licensure. These activities are necessary for the government to monitor government programs, eligibility or compliance, and to enforce health-related civil rights and criminal laws

      ❖ Lawsuits and Disputes

      If you are involved in a lawsuit or in administrative disputes, we may disclose medical information about you in response to court or administrative orders

      ❖ Coroners, Medical Examiners and Funeral Directors

      We may release medical information to a coroner or medical examiner when authorized by law (e.g., to identify a deceased person or determine the cause of death). We may also release medical information about patients to funeral directors.

      ❖ Inmates

      If you are an inmate of a correctional facility, we may release medical information about you to the correctional facility so that the facility can provide you with treatment.

      Your Rights Regarding Your Medical Information

      You have the following rights concerning your medical information.

      ❖ Right to Inspect and Copy:

      You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records, but does not include psychotherapy notes. You must submit a request in writing to the Practice Manager and/or this office's Privacy Officer if you wish to inspect and copy medical information that may be used to make decisions about you. If you request a copy of the information, this Practice may charge you a fee for copying, mailing, or summarizing your medical records. You must submit a written request if you wish to view your psychotherapy notes.

      We may deny your request to inspect and copy your records because of special circumstances. If you are denied access to medical information including psychotherapy notes, you may request that we review our denial. Another licensed health care professional chosen by this Practice will review your request and our denial. The person conducting the review will not be the person who denied your initial request. This Practice will comply with the outcome of the review.

      ❖ Right to Amend:

      If you feel that medical information maintained about you is incorrect or incomplete, you may ask the Practice to amend the information. You have the right to request an amendment of your information for as long as the information is kept by the Practice.

      To request an amendment, your request must be made in writing and submitted to the Practice Manager and/or Privacy Officer of this Practice. In addition, you must provide a reason to support your request.

      We may deny your request to amend your medical records if your request is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

      • Was not created by this Practice unless the person (doctor) or other health care entity that created the information is no longer available to make the amendment for you;
      • Is not part of the medical information about you kept by the Practice;
      • Is not part of the information which you would be permitted to inspect and copy; or
      • Is accurate and complete as is

      ❖ Right to Accounting of Disclosures

      You have the right to request an accounting of disclosures of your medical information made by the Practice for purposes other than treatment, payment, or health care operations.

      To request this accounting, you must submit your request in writing to the Practice Manager and/or Privacy Officer of this Practice. Your request must state how long a period of time you wish the accounting to cover. The accounting cannot exceed a period of six (6) years beginning April 14, 2003. Your request should indicate in what format you want the accounting (paper or electronically). The first accounting you request within a 12-month period will be free. You may be charged for additional accountings within the same 12-month period. We will notify you of the cost so that you may choose to withdraw or modify your request if costs seem excessive.

      ❖ Right to Request Restrictions

      You have the right to request a restriction or limitation on the medical information the Practice uses or discloses for your treatment, payment or health care. You also have the right to request a limit on the medical information the Practice discloses about you to someone outside the Practice for care or payment. This Practice is not required to agree to your request. Should this Practice agree to your request, we will comply with your request unless the information is needed to provide you emergency treatment.

      To request restrictions, you must make your request in writing to the Practice Manager and/or Privacy Officer of this Practice. In your request, you must indicate:

      1. What information you want to limit;
      2. Whether you want to limit your information for our own use and disclosure;
      3. To whom you want the limits to apply.

      ❖ Right to Request Confidential Communications

      You have the right to request that this Practice communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that this Practice contact you only at work or by mail.

      If you want to request that we communicate with you in a certain manner, you must make your request in writing to the Practice Manager and/or Privacy Officer of this Practice. You do not have to state a reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish the communication to be directed.

      ❖ Right to Question Your Bill and Billing Procedures

      If you wish your bill sent to another address, or if you have questions regarding your bill and the Practice's billing procedures, you may direct you questions and concerns to this Practice's Office Manager.

      Changes to This Notice

      We reserve the right to change our practices and to make new provisions effective for all the protected health information we maintain. Should our information practices change, we will post the amended NOTICE OF PRIVACY PRACTICES in the office waiting area and on our website (if applicable). You may request that a copy be provided to you by contacting the Practice Manager and/or Privacy Officer of this Practice.


      If you believe your privacy rights have been violated, you may file a complaint with the Practice Manager and/or Privacy Officer of this Practice or with the Office for Civil Rights, U.S. Department of Health and Human Services.

      To file a complaint with this Practice, contact: Privacy Officer: Melanie Tsen (830) 372-9042

      All complaints to the Office for Civil Rights should be submitted in writing.
      The address for the Office of Civil Rights is:

      Office for Civil Rights
      U.S. Department of Health and Human Services
      200 Independence Avenue, S.W.
      Room 509F, HHH Building
      Washington, D.C. 20201

      Your complaint must be filed within 180 days of when you knew or should have known that the act occurred.
      You will NOT be penalized for filing a complaint.


      I acknowledge that this Practice has provided me with a written copy of the Notice of Privacy Practices.

      I understand that as provided in the Notice of Privacy Practices, the terms of the Notice may change. If they do, I may obtain a revised copy from the Privacy Officer by calling 830-372-9042.

      I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.

      I understand that I may revoke this consent in writing, except to the extent that Physician has already taken action in reliance thereon. I also understand that by refusing to sign or revoking this consent, Physician may refuse to treat me. I wish to restrict the use or disclosure of my health information as follows:

      Please list who you want to release information to:

      Add more

      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.

      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.


      Name: Southwest Gastroenterology, P.A.
      Address: 911 S State Hwy 123 Bypass Seguin, Tx 78155

      Risks of using email

      The physician offers patients the opportunity to communicate by email. Transmitting patient information poses several risks of which the patient should be aware. The patient should not agree to communicate with the physician via email without understanding and accepting these risks. The risks include, but are not limited to, the following:

      • The privacy and security of email communication cannot be guaranteed.
      • Employers and online services may have a legal right to inspect and keep emails that pass through their system.
      • Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent.
      • Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer.
      • Email can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of the physician or the patient. Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients.
      • Email is indelible. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace.
      • Use of email to discuss sensitive information can increase the risk of such information being disclosed to third parties.
      • Email can be used as evidence in court.
      • The physician uses encryption software as a security mechanism for email communications.

      The patient:

      • Agrees to and will comply with the use of encryption software.
      • Chooses not to use encryption software when communicating with the physician, with the full understanding that this increases the risk of violation of the patient’s privacy.

      Conditions of using email

      The physician will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, the physician cannot guarantee the security and confidentiality of email communication. Thus, patients must consent to the use of email for patient information. Consent to the use of email includes agreement with the following conditions:

      • Emails to or from the patient concerning diagnosis or treatment may be printed in full and made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails.
      • The physician may forward emails internally to the physician’s staff and to those involved, as necessary, for diagnosis, treatment, reimbursement, healthcare operations, and other handling. The physician will not, however, forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law.
      • Although the physician will endeavour to read and respond promptly to an email from the patient, the physician cannot guarantee that any particular email will be read and responded to within any particular period of time. Thus, the patient should not use email for medical emergencies or other time-sensitive matters.
      • Email communication is not an appropriate substitute for clinical examinations. The patient is responsible for following up on the physician’s email and for scheduling appointments where warranted.
      • If the patient’s email requires or invites a response from the physician and the patient has not received a response within a reasonable time period it is the patient’s responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond.
      • The patient should not use email for communication regarding sensitive medical information, such as sexually transmitted disease, AIDS/HIV, mental health, developmental disability, or substance abuse. Similarly, the physician will not discuss such matters over email.
      • The patient is responsible for informing the physician of any types of information the patient does not want to be sent by email, in addition to those set out in the bullet above. Such information that the patient does not want communicated over email includes:

      The patient can add to or modify this list at any time by notifying the physician in writing.

      • The physician is not responsible for information loss due to technical failures associated with the patient’s email software or internet service provider

      Instructions for communications by email

      To communicate by email, the patient shall:

      • Limit or avoid using an employer’s or other third party’s computer.
      • Inform the physician of any changes in the patient’s email address.
      • Include in the email: the category of the communication in the email’s subject line, for routing purposes (e.g., ‘prescription renewal’); and the name of the patient inthe body of the email.
      • Review the email to make sure it is clear and that all relevant information is provided before sending to the physician.
      • Inform the physician when the patient receives an email from the physician.
      • Take precautions to preserve the confidentiality of emails, such as using screen savers and safeguarding computer passwords.
      • Withdraw consent only by email or written communication to the physician.
      • Should the patient require immediate assistance, or if the patient’s condition appears serious or rapidly worsens, the patient should not rely on email. Rather, the patient should call the physician’s office for consultation or an appointment, visit the physician’s office or take other measures as appropriate.

      Patient acknowledgement and agreement

      I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email between the physician and me, and consent to the conditions outlined herein, as well as any other instructions that the physician may impose to communicate with patients by email. I acknowledge the physicians right to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered .

      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.