Patient Paperwork

Patient Demographic Form

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?

DOCUMENT UPLOADER: If you have Power of Attorney on file, please upload documentation here. An Advanced Healthcare Directive is also sufficient

PATIENT PORTAL

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

DOCUMENT UPLOADER: Please upload images of the front and back of your Insurance Cards and Government Issued ID.
NOTE: Receipt of these images is required before you may schedule any procedure, or see any provider.

• The information I have provided above is true, accurate, and complete

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

CURRENT MEDICATIONS

MEDICATIONS: Please List the medications you are taking (prescription, over-the-counter, and supplements). Complete each column. Attach additional pages if needed.

ALLERGIES

Past Medical History:

PAST SURGICAL HISTORY:

PAST ENDOSCOPIC HISTORY:

SOCIAL HISTORY

Please select all that apply.

Tobacco Use

Alcohol Use:

Recreational Drug Use:

FAMILY HISTORY

Have your blood relatives had any of the following? If yes, please select the box for their relation to you.

REVIEW OF SYSTEMS:

VACCINATION HISTORY:

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.

CONSENT FOR TREATMENT

• I authorize Daryl M. McClendon, M.D., Jeffrey W. Molloy, M.D., Austin T. Nelson, M.D, Martin P. Kaszubowski, M.D., Terri L. Tope, ANP, and/or Erica J. Heagy, ANP to administer medical treatment and access my electronic prescription records for continued care and further treatment and,
• I hereby authorize the following facilities:
• Providence Medical Center,
• Alaska Regional Hospital,
• Surgery Center of Wasilla, and/or
• Alaska Digestive Center are hereby

to review/access my Alaska Digestive & Liver Disease medical record for treatment and diagnostic record for coordination of care.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

PRIVACY POLICIES ACKNOWLEDGEMENT & CONSENT

I understand that Providers: Daryl M. McClendon, MD, Jeffrey W. Molloy, MD, Austin T. Nelson, MD, Martin P. Kaszubowski, MD, Terri L. Tope, ANP and/or Erica J. Heagy, 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, may be 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 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.

We participate with healtheConnect the Alaska health information exchange (HIE) to share your medical records with your other health care providers and for other limited reasons. You have rights to limit how your medical information is shared. We encourage you to read our Notice of Privacy Practices and find more information about healtheConnect medical record sharing policies. You may visit their website at https://healtheconnectak.org/.

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, 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.

By signing below, I agree that I have reviewed and understand the above information and that I have received or been offered a copy of the Notice of Privacy Practices.

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 for your healthcare needs. We are committed to providing you with the best possible medical care. Prior to your scheduled appointment, please call your insurance company for your benefit coverage. 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 treatment provided. Any balance due must be paid 30 days from the date of service, unless you have contacted our billing office (907)-569-1333 to make payment arrangements.

Returned Checks – A $35.00 charge will be added to your account for any check returned by your bank for any reason. This will be in addition to charges made by your bank.

No show, Canceled, and Rescheduled services – As a specialty provider our office visits schedule several weeks out, we also perform a large volume of procedures which require considerable time and resources to perform. Please be considerate of your fellow patients and our office staff and allow at least 2 business days’ notice for cancellations/rescheduled office visits and 4 business days for procedures. Our office reserves the right to charge patients that do not provide us with the appropriate notification in cancelling/rescheduling the appointment. Our policy is to charge $50.00 for missed office visits and $100 for missed procedures.

Collections – We utilize a collection agency for past due/unpaid accounts over 90 days from the date of service or last payment received. If there are any issues with your account, please contact our office with questions and/or concerns. If there was an insurance issue that was not discussed or resolved prior to your account going to collections, you are responsible for the bill.

INSURED PATIENTS
As a courtesy, our office will bill your primary and secondary insurance for you. We cannot bill your insurance company unless you give us your correct insurance information. Please understand that your medical insurance is a contract between you and your insurance company. We are not party to that contract. Patients are responsible for knowing their coverage limitations and benefits. The billing office cannot guarantee payment for services or quote benefits from your health plan.

• Referrals and Pre-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.
• Procedures – If you receive services at Alaska Digestive Center you will receive a separate bill with a charge for 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.
• Helpful Information – – – You are 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

Patients without insurance will be required to make a deposit at the time of service. New patients are required to bring $250; established patients $175, and colonoscopy procedures are $1029, and Upper Endoscopy $716. 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, Terri L. Tope, ANP, and/or Erica J. Heagy, 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 all provisions of this Patient Financial Responsibility Form.

Medicare Long Term Authorization

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

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree 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?

*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 LiverDisease 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 tore-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.