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:

Primary Care Provider and Referring Provider:

Home Phone #:

May Leave a Message

Yes No

Cell Phone #:

May Leave a 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.

werwer

I authorize Austin T. Nelson, M.D., Daryl M. McClendon, M.D., and/or Jeffrey W. Molloy, M.D. to administer medical treatment.

werwer

I authorize Austin T. Nelson, 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.

werwer

I authorize my insurance company(ies) to pay benefits directly to Austin T. Nelson, 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 Austin T. Nelson, 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.

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