Direct Access Colonoscopy Program

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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.

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

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.

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

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    INFECTION HISTORY

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

    CHRONIC ILLNESSES

    ALLERGIES: Medications, Solutions or Metal

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    PREVIOUS OPERATIONS/HOSPITALIZATIONS *Please list:

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    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 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 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 Ronald J. Boisen, M.D., Daryl M. McClendon, M.D., 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 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.

    If you are not of Medicare age please put N/A

    (Authorization good for one year from the above date)

    A. Notifier: Alaska Digestive and Liver Disease

    If you are not of Medicare age please put N/A

    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.

    If you are not of Medicare age please put N/A

    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

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