Direct Access Colonoscopy Program

Please correct the errors described below.

Welcome to the Direct Access Colonoscopy Program

We are pleased that you have chosen ADLD 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 Alaska Digestive and Liver Disease 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.

ALASKA DIGESTIVE AND LIVER DISEASE, LLC

Ronald J Boisen, M.D. | Daryl M. McClendon, M.D. | Jeffrey W. Molloy, M.D.

Name must be exactly the same as it is on the insurance card.

Primary Insurance

Secondary Medical Insurance

Tertiary Medical Insurance

Patient is responsible for all fees regardless of medical coverage. It is customary to pay at the time of service unless other arrangements have been made in advance. I authorize Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D. to administer medical treatment.

I authorize Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., 3851 Piper Street, Suite U466, Anchorage, AK 99508 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 Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., 3851 Piper Street, Suite U466, Anchorage, AK 99508 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 Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., a fee which I have already paid, I understand that I will be promptly reimbursed.

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.

Phone Message Consent

I acknowledge and agree that (Alaska Digestive and Liver Disease) and any affiliates or vendor thereof, including collection or billing companies, may contact me by email, telephone or text message to any telephonic number or Email address I have provided to you, and any other telephone number associated with my account, including wireless or mobile telephone numbers. I further agree that you may use any method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) Or prerecorded message. I also agree that I will notify (Alaska Digestive and Liver Disease) if I have given up ownership or control of any such telephone number.

Your Right to Privacy

We respect your right to privacy regarding medical information. May we share information with your spouse?

We understand that you may have concerned relatives. Please list names of adult children, other family members and/or contact persons with whom we may share information without additional written consent:

I acknowledge and agree that I have access to print or read the notice of privacy practices for Ronald J. Boisen, M.D., Daryl M. McClendon, M.D., and/or Jeffrey W. Molloy, M.D. on the Alaska Digestive and Liver Disease Website.

Power of Attorney

Definition: A legal document giving a person the power to make decisions for another person, (e.g. current medical decisions, financial decisions).

Appointment and Procedure Cancellation Policy

I understand that RONALD J. BOISEN, M.D; DARYL M. MCCLENDON, M.D. and JEFFREY W.MOLLOY, M.D. reserve the right to the following in the event that you need to reschedule:

  • $25.00 Charge for cancelled office visit without giving at least one (1) business days notice
  • $50.00 Charge for cancelled procedures without giving at least two (2) business days’ notice

This allows other patients to be scheduled into that appointment slot. It also makes it possible to reschedule your appointment more efficiently.

I acknowledge and agree to the terms above. By typing you name here, you are signing this application electronically. You agree you electronic signature is the legal equivalent of your manual signature on this application.

Medicare Long Term Authorization

I request that payment of authorized Medicare Benefits be made on my behalf for any service furnished to me by Ronald J. Boisen, MD, Daryl M. McClendon, MD and/or Jeffrey W. Molloy, MD. I authorize any holder of medical or other information about me release to the Health Care Financing Administration and its agents any information needed to determine these benefits for related services.

(Authorization good for one year from the current date)

Advance Beneficiary Notice of Non-Coverage(ABN)

A. Notifier: Alaska Digestive and Liver Disease.

NOTE: If Medicare doesn't pay for D. Office Visit 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 D. Office Visit below.

D. Office Visit

E. Reason Medicare May not Pay:

Not indicated for diagnosis and or treatment in this case.

F. Estimated Cost

No More than $600

WHAT YOU NEED TO DO NOW:

  • Read this notice, So you can make an informed decision about your care.
  • Ask us any questions that you may have after finishing reading
  • Choose an option below about whether to receive the D. Office Visit. Listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot ewquire us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you

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. IF YOU DO NOT HAVE MEDICARE, PLEASE TYPE N/A

CMS does not discriminate in its program 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.

Reason for Visit

Past Medical/History Problems

Have you ever had?:

Previous Procedures

Hospitalization & Surgery

Family Health History

Gastrointestinal (Digestive Disease)

Relative/s with:

Personal Social History

Review of Systems for the Last 12 months

Constitutional

Eyes

Ears/Nose/Mouth/Throat

Cardiovascular

Respiratory

Skin

Hematological

Gastrointestinal

Neurological

Psychiatric

Endocrine

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.

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