Direct Access Colonoscopy Program

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. To assist us in providing you with the correct information, please indicate why you are having a colonoscopy:

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 Name:

Date:

Patient Demographic Form

Legal Last Name:

Legal First Name:

Middle Name:

Social Security Number (VA and Tri‐Care Patients Only):

DOB:

Gender:

Male Female Other

If Other, please specify:

Address:

City:

State:

Zip:

What is Your Race? (Check one or more)

Alaskan Native

Asian

Black/African American

Multi‐Racial

Native American

Native Hawaiian/Pacific Islander

White

Unknown

Other

If Other, please specify:

Primary Language:

Hispanic Origin?

Yes No

Marital Status:

Medical Providers Involved in my Care

Home Phone #:

May Leave a Message

Yes No

Cell Phone #:

May Leave a Message

Yes No

Would you like to receive Auto Appointment Reminders?

Yes No

Preferred Method of Contact for appointment reminders:

Voice Message:

Yes No

SMS Message:

Yes No

Spouse Name:

Spouse DOB:

Preferred Pharmacy:

Preferred Pharmacy's Location:

Employer:

Employer Phone:

Emergency Contact Name:

Relationship:

Phone #:

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.

Email Address:

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

Identification and Insurance Cards

Add file

Please upload a file

Primary Insurance

Primary Insurance Name:

ID Number:

Group Number:

Policy Holder’s Name:

Relationship of Policy Holder to you:

Medical Claims Submission Address:

Policy Holder’s Date of Birth:

Secondary Medical Insurance

Secondary Insurance Name:

ID Number:

Group Number:

Policy Holder’s Name:

Relationship of Policy Holder to you:

Medical Claims Submission Address:

Policy Holder’s Date of Birth:

Tertiary Medical Insurance

Tertiary Insurance Name:

ID Number:

Group Number:

Policy Holder’s Name:

Relationship of Policy Holder to you:

Medical Claims Submission Address:

Policy Holder’s Date of Birth:

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 authorize 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. to to administer medical treatment.

I authorize 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., 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 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., 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 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., a fee which I have already paid, I understand that I will be promptly reimbursed.

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's Name:

Today's Date:

Patient Medical History Form

REASON FOR VISIT:

CURRENT MEDICATIONS

Upload list of medications here:

Add file

Please upload a file

Medication Name:

Dose:

Frequency:

Add new row

If Other, please specify:

INFECTION HISTORY

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

Have you had the following vaccinations:

Tetanus/T-Dap

Flu

Hepatitis B

Pneumonia

Shingles

Please include dates of the last vaccines you received:

CHRONIC ILLNESSES

If Other, please specify:

Have You Ever Had?

Colon Polyps

Colonoscopy

Upper Endoscopy

Blood Transfusion

Ulcers

Liver Disease

Pancreatitis

Cancer

If Colonoscopy is selected, please specify year:

If Upper Endoscopy is selected, please specify year:

If Cancer is selected, please specify type:

ALLERGIES: Medications, Solutions or Metal

Medication, Solution or Metal Name:

Allergic Reaction:

Add new row

PREVIOUS OPERATIONS/HOSPITALIZATIONS *Please list:

Type:

Year:

Reason:

Add new row

Have you ever had anesthesia complications?

Yes No

Please describe if answered Yes:

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?

Crohn’s or Ulcerative Colitis

Yes No

If Yes, please specify relationship:

Pancreatitis

Yes No

If Yes, please specify relationship:

Ulcer

Yes No

If Yes, please specify relationship:

Polyps

Yes No

If Yes, please specify relationship:

Liver Disease

Yes No

If Yes, please specify relationship:

Cancer (Specify Type)

Yes No

If Yes, please specify relationship and the cancer type:

Celiac Sprue

Yes No

If Yes, please specify relationship:

Other:

Yes No

If Yes, please specify illness and indicate relationship:

SOCIAL HISTORY

Tobacco Use?

Chewing Tobacco

E-Cigarettes

Cigarettes

Never Smoked

Former Smoker

If Cigarettes is selected, how many packs per day?

If Former Smoker is selected, please specify quit date:

Drug Use?

Meth

Cocaine

Marijuana

IV Drugs

Other

If Other is selected, please specify:

Alcohol Use?

Do you drink?

Yes No

If Yes, please specify Drinks Per Week:

Other:

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

GENERAL

Unexpected Weight Loss

Unexpected Weight Gain

Fever

Fatigue

EYES

Blurred/Double Vision

Glaucoma

EARS, NOSE & THROAT

Hearing Loss

Ringing in Ears

Mouth Sores

Your Right to Privacy

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

If so, their Name:

Contact Number:

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:

Name:

Relationship:

Contact Number:

Name:

Relationship:

Contact Number:

I authorize 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. to access my electronic prescription records for continued care and further treatment.

The following facilities (PAMC, ARH, and/or Alaska Digestive Center) are hereby authorized to review/access my Alaska Digestive and Liver Disease medical record, treatment record and diagnostic record.

I Acknowledge and agree that I have access to print or read the notice of Privacy Practices for 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 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.

Printed Name:

Date:

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).

Do you have a power of attorney on file?

Yes No

Name of person who holds Power of Attorney:

Phone Number:

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.

Patient Name:

Date

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.

Name:

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

Date:

(Authorization good for one year from the above date)

A. Notifier: Alaska Digestive and Liver Disease

B. Patient Name:

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

C. Identification Number:

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.

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

OPTION 1. I want the Services To Be Provided listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the Services To Be Provided listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I can not appeal if Medicare is not billed. OPTION 3. I don't want the Services To Be Provided listed above. I understand with this choice, I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

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.

I. Name:

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

J. Date:

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?

Black Lung

No Yes

Research Grant

No Yes

Veterans Affairs

No Yes

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

2. Was the illness/injury due to a work-related accident/condition?

No Yes

(If yes, STOP – Medicare is secondary)

3. Was illness/injury due to a non-work related accident?

No Yes

(If yes, STOP – Medicare is secondary)

4. Are you entitled to Medicare based on:

Age Disability End Stage Renal Disease

5. Do you have health insurance sponsored through your own or spouse's employer?

No Yes

(If NO – Proceed to question 7)

6. Does the employer that sponsors your insurance plan employ 100 or more employees?

No Yes

(If yes, STOP – Medicare is secondary)

7. Are you currently a patient in a skilled nursing facility (SNF) such as a nursing home?

No Yes

(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.

Patient Signature:

Date:

Did you upload a copy of your insurance and driver license?

Yes No

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

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

PATIENT

Name:

Birth Date:

Other Names Used:

FROM

I request patient’s information be sent by:

Dr. Daryl M. McClendon

Dr. Jeffrey W. Molloy

Dr. Austin T. Nelson

Dr. Martin P. Kaszubowski

Dr. Terri L. Tope

Another health care provider name here:

If checked, please specify:

PROVIDE TO

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

Name:

Phone Number:

How do you want the medical information to be sent?

It will be picked up.

Fax to:

If checked, please specify:

Mail to this address:

If checked, please specify:

Other:

If checked, please describe:

*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

Please check or describe the health information that you would like disclosed:

Complete Record

Consultations

Medications Records

Discharge Summaries

Physician Reports

Pathology Reports

History & Physical Exams

Radiology & Imaging Reports

Laboratory Results

Records for the following dates or treatment:

If checked, please specify:

Other:

If checked, please specify:

Specific Sensitive Information needs to be initialed to be disclosed:

Mental/Behavioral Health Treatment

Drug/Alcohol Abuse

HIV/AIDS Information

STD Treatment

PURPOSE

Why are you requesting this disclosure?

PersonalUse

Legal

Insurance

Continuation of Care

Second Opinion

Other:

If Other, please specify:

VALIDITY

Expiration: This authorization will expire one (1) year from the signature date, unless an alternative expiration date is provided here:

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.

Signature:

Date:

Relationship to Patient:

Self Parent/Guardian Legally Authorized Representative Other:

If Other, please specify:

OFFICE USE ONLY:

Verification Method:

Please select:

Priority Archive

Sent by:

Mail

Fax

Other:

If Other, please specify:

Date Sent:

Staff Initials:

My initials below confirm that the above is still accurate as of the date indicated:

Your information will be encrypted.

Alaska Digestive and Liver Disease

You may print the below forms in pdf format or contact our office to receive the forms in person, by mail, or by fax.

(907) 569-1333
www.alaskagi.com/docs/colonoscopy-form-new.pdf
3851 Piper St Suite U466, Anchorage, AK, 99508-4684, USA