Patient Information

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Emergency Contact

Pharmacy

Insurance Information

Medications

Medical History

Past Surgeries

Social History

Permission to discuss medical care: The following individuals are allowed by the staff of Gastrointestinal Medicine Associates, to discuss any and all issues concerning my medical care. NOTE that unless Gastrointestinal medicine Associates is notified by you in person or by certified mail, the individuals listed for permission to discuss medical care shall remain in effect indefinitely (please list their name and your relation).

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When it is necessary to contact you by phone, i.e. to confirm or cancel an appointment, or give information to you regarding a booking or test that our office has scheduled on your behalf etc; may we call the telephone numbers that you have provided, and if you are not available may we:

Patients with and without Health Insurance

I hereby authorize Gastrointestinal Medicine Associates, Inc., to release information to my insurance carrier(s) regarding my medical services and treatment in order to file a claim. I hereby assign all payments for medical services rendered to myself and dependents. I understand that I am financially liable for any co-pays, cost share, deductible, or co-insurance rendered to myself or dependents. I am responsible to pay within 30 days of my first bill or I will be subject to a 1.5% interest charge per month. If it becomes necessary to file suit to collect this bill, I agree to pay court costs and reasonable attorney fees to the extent permitted by law. Consequently, If I am uninsured, I understand that I am financially responsible for any and all services rendered to me by Gastrointestinal Medicine Associates, Inc. Payment is due at the time of service unless other arrangements have been made. I am responsible to pay within 30 days of my first bill or I will be subject to a 1.5% interest charge per month. If it becomes necessary to file suit to collect this bill, I agree to pay court costs and reasonable attorney fees to the extent permitted by law. A copy of this signature is valid as the original.

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