Direct Access Colonoscopy Program

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 Demographic Form

Preferred Method of Contact for appointment reminders:

Alaska Digestive and Liver Disease 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 Alaska Digestive and Liver Disease.

Please upload copies of your identification and insurance cards here prior to proceeding.

Primary Insurance

Secondary Medical Insurance

Tertiary Medical Insurance

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 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.

Patient Medical History Form

CURRENT MEDICATIONS

INFECTION HISTORY

*Please select "Yes" if you currently have or have had:

CHRONIC ILLNESSES

ALLERGIES: Medications, Solutions or Metal

PREVIOUS OPERATIONS/HOSPITALIZATIONS *Please list:

FAMILY HISTORY

PLEASE INDICATE WITH RELATIONSHIP (i.e. father): Do you know of any blood relatives who have or have had any of the following?

SOCIAL HISTORY

Alcohol Use?

REVIEW OF SYSTEMS * As you review the following list, please select ALL which have significantly affected you:

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 have read, acknowledged 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.

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 Daryl M. McClendon, M.D., Jeffrey W. Molloy, M.D.,Austin T. Nelson, M.D, Martin P. Kaszubowski, M.D., and/or Terri L. Tope, ANP reserve the right to the following in the event that you need to reschedule:

• $50.00 Charge for cancelled office visit without giving at least two(2) business days' notice.
• $100.00 Charge for cancelled procedures without giving at least four(4) business days' notice.

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.

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.

Medicare Long Term Authorization

I request that payment of authorized Medicare Benefits be made on my behalf for any service furnished to me by Daryl M. McClendon, M.D., Jeffrey W. Molloy, M.D., Austin T. Nelson, M.D, Martin P. Kaszubowski, M.D., and/or Terri L. Tope, ANP . 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.

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.

(Authorization good for one year from the above date)

A. Notifier: Alaska Digestive and Liver Disease

Advance Beneficiary Notice of Non-Coverage(ABN)

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

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 Services To Be Provided 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 require us to do this.

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.

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.

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

Medicare Secondary Payer Questionnaire

1. Are you receiving benefits from any of the following programs?

(If yes to any of the above, STOP – Medicare is secondary)

(If yes, STOP – Medicare is secondary)

(If yes, STOP – Medicare is secondary)

(If NO – Proceed to question 7)

(If yes, STOP – Medicare is secondary)

(If yes, we will bill SNF, not Medicare)

I confirm that to the best of my knowledge, the above information is accurate.

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.

If no, please be aware we are unable to schedule you without proper identification and insurance information. Thank you for your understanding.

Acknowledgement and Consent

I understand that Providers: Daryl M. McClendon, MD, Jeffrey W. Molloy, MD, Austin T. Nelson, MD, Martin P. Kaszubowski, MD, and/or Terri L. Tope, ANP (Referred to below as "The Providers") will use and disclose health information about me.

I understand that my health information may include information both created and received by the practice, maybe in the form of written or electronic records or spoken words, and may include information About my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that The Providers’ may use and disclose my health information in order to:

• Make decisions about and plan for my care and treatment;
• Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment.
• Determine my eligibility for a health plan or insurance coverage, and submit bills, claims, and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
• Perform various offices, administrative, and business functions that support my physician's efforts to provide me with, arrange, and be reimbursed for quality, cost-effective health care.

I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of The Providers’, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in the waiting/reception area.

I understand that I have the right to ask that some and/or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and understand that "The Providers" is not required by law to agree to such requests.

Your Right to Privacy

We understand that you may have concerned relatives and we respect your right to privacy regarding medical information. Please list the names of individuals with whom we may share information without additional written consent.

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.

Financial Policy

Thank you for choosing Alaska Digestive and Liver Disease, LLC to participate in your healthcare needs. Prior to your scheduled appointment, please call your insurance company for your benefit coverage. You must bring your insurance card and photo I.D. with you. Without these, you will be responsible to pay for any charges incurred on the date of service in which treatment is provided. The following information outlines your financial responsibilities related to payment for professional services.

ALL PATIENTS
Patients are responsible for any charges incurred on the account resulting from the treatment provided. Any balance due must be paid 90 days from the date of service unless you have contacted our billing office (907)-569-1333 to make payment arrangements.

Cancellations/Reschedules/No-Show
Drs. Daryl M. McClendon, Jeffrey W. Molloy, Austin Nelson, Martin P. Kaszubowski, and ANP Terri L. Tope reserve the right to charge patients that do not provide us with the appropriate notification in canceling/rescheduling the appointment. Our office requires 2 business days for Office Visits and 4 business days for procedures. Our policy is to charge $50.00 for office visits and $100 for procedures. This allows other patients to be scheduled into the appointment slot and for you to be efficiently rescheduled.

Collections
Should your account become delinquent and over 90 days old we will utilize a collection agency for any past due/unpaid accounts.

INSURED PATIENTS
At ADLD, we will happily bill your insurance for you as a courtesy. It is the patient’s responsibility to provide our office with current insurance information. We will ask for your insurance card at your first visit and will make a copy for our records. We will request a copy at each office visit thereafter. If current information is not obtained at the time of service, it will become the patient’s responsibility to pay the entire balance until current information is provided to our office.

• Eligibility and Coverage - Please remember that your insurance policy is a contract between you and your insurance company. Due to the many different insurance plans out there, our office cannot guarantee your eligibility and coverage. You are responsible for knowing your eligibility and coverage information.
• Referrals and Authorizations - Our billing office will attempt to obtain a referral or pre-authorization if your plan requires one. If you choose to be seen prior to receiving the referral or authorization, your insurance may not pay for your appointment and this will ultimately become the patient's responsibility.
• Procedure Statements - If you receive services at Alaska Digestive Center you will receive a separate bill from the facility and a separate bill for the physician’s time. You may also receive separate bills for anesthesia and any laboratory or pathology services. If your procedure is performed in the hospital you will receive separate bills from the hospital.
• Additional Information - You is responsible for your bill whether your insurance pays or not. To assist you in finding benefit coverage for your plan, call your insurance company with the following information: Provider Name, Provider tax ID if available, and Procedure(s) to be performed.

UNINSURED PATIENTS

All uninsured patients are eligible for a discount of 30 % of billed charges if payment is received in full on or before the date of service. Discounts offered under this policy are contingent on full payment of the agreed amount and generally will not be applied to account balances until the agreed amount has been paid in full. If there is a balance remaining you will receive a statement.

AUTHORIZATION

• I authorize providers Daryl M. McClendon, MD, Jeffrey W. Molloy, MD, Austin T. Nelson, MD, Martin P. Kaszubowski, MD, and/or Terri L. Tope, ANP to submit claims for benefits without obtaining my signature on each and every claim.
• I authorize my insurance(s) benefits to be paid to providers Daryl M. McClendon, MD, Jeffrey W. Molloy, MD, Austin T. Nelson, MD, Martin P. Kaszubowski, MD, and/or Terri L. Tope, ANP. 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.
• I have read, understand, and agree to the provisions of this Patient Financial Responsibility Form:

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.

Advanced Beneficiary Notice of Noncoverage (ABN)

NOTE: : If Medicare doesn’t pay for D. 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. below

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 you finish reading.
• Choose an option below about whether to receive the D. 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 require us to do this

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

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 OMP control number. The valid OMB control number for this information collection is 0938-0566. This 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 the 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.

Medicare Long Term Authorization

I request that payment of authorized Medicare Benefits be made on my behalf for any service furnished to me by Daryl M. McClendon, M.D., Jeffrey W. Molloy, M.D., Austin T. Nelson, M.D, Martin P. Kaszubowski, M.D., and/or Terri L. Tope, ANP. I authorize any holder of medical or other information about me be released to the Health Care Financing Administration and its agents for any information needed to determine these benefits for related services.

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.

(Authorization good for one year from the above date)

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

PATIENT

FROM

PROVIDE TO

Who do you want the patient information to be sent to?

How do you want the medical information to be sent?

*Sending information by Fax increases privacy risks, as they involve increased risk of accidental disclosure. Information sent electronically may also be vulnerable to cyber-attack.

REQUESTED INFORMATION

PURPOSE

VALIDITY

Revocation: An authorization may be revoked at any time by written notice to Alaska Digestive and Liver Disease 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.

PATIENT RIGHTS

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 - ADLD 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 ADLD by contacting Health Information Management. I may be charged a reasonable fee for copying costs.

REQUESTOR

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.

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.

OFFICE USE ONLY: