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Patient Interview Form

Person(s) to whom WGA may disclose/discuss my Personal Health Information / PHI:

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I hereby assign, transfer, and set over to Waco Gastroenterology Associates, PA (WGA) all of my rights, title, and interest to my . medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization will remain valid until I revoke it in writing. I understand that I am financially responsible for all charges whether or not they are covered by insurance. I request and give my consent to WGA to provide and perform such medical services as are considered necessary of beneficial by my healthcare provider for my health and well-being. I acknowledge WGA makes no representations, warranties or guarantees as to the results or cures. WGA has made available to me a copy of its Notice of Privacy Practices, Patient Rights, and Responsibilities and Patient Financial Policy and agree to abide by such policies. A photocopy, facsimile or digital copy of this document is valid as the original.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Information


Diagnostic Studies/Test

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Previous Procedures

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Current Medications

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Consent to Import Medication History

Past or Present Medical Conditions

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Social History




Drug Use


Review Of Systems

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Consent to Share Data

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