Direct Access Colonoscopy Program
We are pleased that you have chosen Summit Digestive & Liver Disease Specialists as your Gastroenterology provider. You and your primary care provider have determined that you need a colonoscopy. Colonoscopy is a medical procedure during which a flexible tube is used to look inside the colon.
The Summit Digestive and Liver Disease Specialists Clinic strives to provide compassionate and high quality medical care to patients. Please note that without a full consultation it is possible that there are gastrointestinal issues that may not be addressed in the direct access program. If you would rather see the gastroenterologist in consultation we will provide you with an appointment. For a direct access colonoscopy, you will not meet the gastroenterologist in person until the day of your procedure.
You have been identified as having minimal medical problems which do not require a consultation to review. We ask that you complete our patient packet and submit it prior to being scheduled for your procedure. After your information is received and reviewed, our office staff will call you to schedule your procedure and give you bowel preparation instructions.
Please note that some insurance carriers do not cover colonoscopy as a screening procedure for colorectal cancer. You should check with your insurance carrier to confirm coverage and benefits. We are happy to provide procedure and diagnosis codes at your request for you to provide to your insurance company. To assist us in providing you with the correct information.
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
Summit Digestive and Liver Disease Specialists has a secure and confidential Internet‐based portal to enhance communication with our clients. You can use the portal to review your medication, check your latest test results, request prescription refills, and more – 24 hours a day. By providing your email, you are consenting to receive email communications from Summit Digestive and Liver Disease Specialists
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Definition: A legal document giving a person the power to make decisions for another person, (e.g. current medical decisions, financial decisions).
I understand that David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, Albert Saporta, M.D., and/or the Nurse Practitioners, reserve the right to the following in the event that you need to reschedule
This allows other patients to be scheduled into the appointment slot and for you to be efficiently rescheduled.
I have read, acknowledged and agree to the terms above
I request that payment of authorized Medicare Benefits be made on my behalf for any service furnished to me by David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, Albert Saporta, M.D., and/or the Nurse Practitioners. I authorize any holder of medical or other information about me release to the Health Care Financing Administration and its agents for any information needed to determine these benefits for related services
(Authorization good for one year from the above date
A. Notifier: Summit Digestive and Liver Disease Specialists
NOTE: If Medicare doesn't pay for Services To Be Provided below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the Services To Be Provided below
E. Reason Medicare May not Pay: Not indicated for diagnosis and or treatment in this case.
F. Estimated Cost: No More than $600
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this
G. OPTIONS: Check only one box. We cannot choose a box for you
OPTION 1. I want the Services To Be Provided listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 2. I want the Services To Be Provided listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I can not appeal if Medicare is not billed.
OPTION 3. I don't want the Services To Be Provided listed above. I understand with this choice, I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
H. Additional Information
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE(1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy
CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data
resources, gather data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn; PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (Exp. 03/2020)
Form Approved OMB No. 0938-0566
1. Are you receiving benefits from any of the following programs?
(If yes to any of the above, STOP – Medicare is secondary)
I confirm that to the best of my knowledge, the above information is accurate
If no, please be aware we are unable to schedule you without proper identification and insurance information. Thank you for your understanding
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Revocation: An authorization may be revoked at any time by written notice to Summit Digestive and Liver Disease Specialists Management. Revocation is not effective until notice is received and is not effective regarding disclosures made before revocation and where authorization was obtained as a condition of insurance coverage.
I understand that: (1) I have a right to receive a copy of this signed authorization upon request; (2) I have a right to refuse to sign this authorization - SUMMIT DIGESTIVE AND LIVER DISEASE SPECIALISTS may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on a decision to sign this form; and (3) I have a right to inspect or copy my health information. I may arrange to inspect or copy information maintained by SUMMIT DIGESTIVE AND LIVER DISEASE SPECIALISTS by contacting Health Information Management. I may be charged a reasonable fee for copying costs.
I authorize the disclosure of health information described above. Information released under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by Federal privacy standards, including HIPAA and the Privacy Act of 1974. A photo copy/fax of this form is as valid as the original.
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