Summit Digestive & Liver Disease Specialists

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Summit Digestive & 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 & Liver Disease Specialists

Email address

Please upload copies of your identification and insurance cards here prior to proceeding. We are unable to schedule you without proper identification and insurance information. Thank you for your understanding.

Identification and Insurance Cards

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Primary Care Physician

Primary Care Physician Name

Primary Care Physician Phone Number

Primary Insurance

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Self Pay (Check One):

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Secondary Medical Insurance

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Tertiary Medical Insurance

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Patient is responsible for all fees regardless of medical coverage. It is customary to pay at time of service unless other arrangements have been made in advance.

I authorize David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, Albert Saporta, M.D., and/or the Nurse Practitioners, to administer medical treatment

I authorize David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, Albert Saporta, M.D., and/or the Nurse Practitioners, to release any medical information required by my insurance company or Worker’s Compensation carrier for the processing of all medical claims on my behalf

I authorize my insurance company(ies) to pay benefits directly to David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, Albert Saporta, M.D., and/or the Nurse Practitioners, for claims on my behalf. I agree to promptly sign over any checks that I receive within 7 days of receipt. I understand that those charges not covered by my insurance company are my own responsibility, and there is a monthly charge of 1% on the account over 90 days. In the event that my insurance company pays David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, Albert Saporta, M.D., and/or the Nurse Practitioners, a fee which I have already paid, I understand that I will be promptly reimbursed.

I acknowledge and agree to the terms above

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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