New Patient Packet

Welcome to our office,

Your initial visit is for an office consultation only. The medical necessity of any procedure such as upper endoscopy, colonoscopy, and/or any other diagnostic testing will be determined at the consultation. There is NO Special preparation for this consultation.

Please plan to arrive 15 minutes early for your first appointment.

Patient Information

Name

Date of Birth

Address: (Street)

Social Security Number

Address: (City, State, Zip)

Age

Sex

Home Phone

Cell Phone

Race

Ethnicity

Language

Marital Status

Email address

Mailing Address Same as Patient Address

Mailing Address: (Street)

Mailing Address: (City, State, Zip)

May we contact you at work?

Yes No

Employer Name

Work Phone

PCP/Referring Doctor

May we leave a detailed message on your answering machine?

Yes No

Emergency Contact

Home Phone

Responsible Party/Guarantor Information

Responsible Party Same as Patient

Name

Date of Birth

Address: (Street)

Social Security Number

Address: (City, State, Zip)

Home Phone

May we contact you at work?

Yes No

Work Phone

Primary Insurance Information

Self or

Subscriber Name

Address: (Street)

Date of Birth

Address: (City, State, Zip)

Social Security Number

Home Phone

Sex

Relationship to Patient

Insurance Company Name

Policy ID

Group ID

Effective Date

Employer Name

Work Phone

Secondary Insurance Information

Self or

Subscriber Name

Address: (Street)

Date of Birth

Address: (City, State, Zip)

Social Security Number

Home Phone

Sex

Relationship to Patient

Insurance Company Name

Policy ID

Group ID

Effective Date

Employer Name

Work Phone

Tertiary Insurance Information

Self or

Subscriber Name

Address: (Street)

Date of Birth

Address: (City, State, Zip)

Social Security Number

Home Phone

Sex

Relationship to Patient

Insurance Company Name

Policy ID

Group ID

Effective Date

Employer Name

Work Phone

Confidentiality and Privacy under HIPPA

(Health Insurance Portability and Accountability Act of 1996)

I acknowledge receipt of the Notice of Privacy Practices of Gastroenterology Associates.

I acknowledge having already received the Notice of Privacy Practices of Gastroenterology Associates.

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.

Patient/Guardian Signature

Date

Patient Name

Date of Birth

Please read carefully:

All charges (e.g., co-pay, deductibles, self-pay, etc.) are due at the time professional services are rendered.
For those services provided and submitted to my insurance company, I hereby authorize payment of medical benefits to Gastroenterology Associates.
The patient is responsible for all fees. $150.00 deposit fee required on all procedures.
The fee ticket may be used to file insurance claims.
For minor: I understand that I am fully responsible for this minor's medical charges and agree to pay all charges for services rendered by Gastroenterology Associates.
I hereby authorize Gastroenterology Associates to furnish information to any insurance company or authorized agency specified regarding information concerning my medical care.
If my account becomes assigned to a collection agency, I agree to pay a 25% collection fee, court costs, and attorney fees, as allowed by law.
Any check returned to us as unpaid will be charged a $50 fee.
There may be a $25 charge for no show appointments.

Signature of Patient and/or Guardian

Date

Consent for Treatment

I authorize providers at Gastroenterology Associates to perform examinations, procedures, laboratory tests and to administer such medications as, in his or her opinion, as necessary for my care.

Patient Signature

Date

Consent for Medication History

I consent to the use of my medication history from participating medical information exchanges

I have chosen to opt out of this program:

Patient Signature

Date

Release of Information

Often it is difficult to reach a patient to convey physician orders or test results. In this event, with your signed authorization, we would release such information to a person you designate. Please complete the section below.

I authorize Gastroenterology Associates to release any information required in the course of my examination or treatment to the following designated persons:

Add new row

Signature

Date

Patient/Guardian Signature

Date

Your information will be encrypted.