PROCEDURE CONSENT FORMS

Patient Name

Date of Birth

What facility are you scheduled at? Please refer back to the procedure information email

Woodburn Endoscopy Center Inova McLean Ambulatory Surgery Center Inova Fairfax Hospital

I consent to have the following diagnostic examination performed by Dr. Goldstein, Dr. Prosky, or Dr. Vemana.

Upper Endoscopy (EGD) - Examination of the esophagus (food pipe), stomach, and duodenum (first portion of the small intestine) Please click "with biopsy" if you are scheduled for an endoscopy

with biopsy

with dilation of the esophagus

Please click this only if you have a "43249" as your procedure code (please refer back to procedure information email)

Colonoscopy - Examination of the Colon Please click both if you are scheduled for a colonoscopy

with biopsy

with polypectomy (removal of small growths using a wire loop or an electrical current)

Other (Video Capsule Endoscopy, Flex Sigmoidoscopy, etc.)

It will be noted in the procedure information email what you are scheduled for.

Do you have Medicare? Due to Medicare's procedure policies, filling these additional consent forms will allow us to appeal claims in the case that it is rejected.

Yes I am covered by Medicare No I am not covered by Medicare

Notifier: Advanced Digestive Care, LLC

Patient's Name

Medicare Identification Number

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare doesn't pay for D. Colonoscopy 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 D. Colonoscopy below.

D. Colonoscopy

E. Reason Medicare May Not Pay:

F. Estimated Cost

G0121 or G0105

Screening coverage for Colonoscopies is only provided once every 10 years, if the patient is not in a higher risk category.

$220

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 you finish reading.
Choose an option below about whether to receive the D. COLONOSCOPY 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 D.

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 aMedicare 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 minus co-pays and/ or deductible

OPTION 2.

I want the D.

listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

OPTION 3.

I don't want the D.

listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare will 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. Signature

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 :u:e required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB 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 the 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 Repons Clearance Officer, Baltimore, 1faryland 21244-1850.

Please read the following statements:
I understand that there may be risks associated with any endoscopic examination. Potential complications may include risk of drug reaction, localized swelling of the arm following intravenous medication, or bleeding. Serious complications such as bleeding or perforation of the intestinal wall can occur but are usually associated with polypectomy or dilation. Excessive bleeding may require blood transfusions and perforation may require surgical intervention.

I understand that these procedures are not always accurate and that diagnostic errors can occur.
If any unforeseen condition arises during this procedure, I authorize Dr. Goldstein, Dr. Prosky, or Dr. Vemana to do whatever is deemed medically necessary.
Please note that there is a professional fee, a facility fee, an anesthesia fee, and possibly a pathology fee associated with this procedure. You will receive separate bills for each fee. If you have questions about your out of pocket expense you should contact your insurance carrier.

Procedure Cancellation/Rescheduling Policy: (Please initial to acknowledge the statements below.)

Northern Virginia Gastrointestinal Associates, a division of Advanced Digestive Care, requires 7 business days' notice prior to canceling or rescheduling your procedure. There will be a $350 fee assessed for failing to appear for your scheduled procedure or for not providing 7 business days notice to cancel/reschedule.

Transportation Policy: (Please initial to acknowledge the statements below.)

You MUST make arrangements for an adult (18+) to drive you home.
YOU MAY NOT TAKE A TAXI, UBER, or LYFT unless accompanied by an adult (18+). The facility you are scheduled with has reserved the right to confirm your transportation prior to your procedure
If you do not have a confirmed ride, your procedure will be cancelled.
If your procedure is scheduled at Woodburn Endoscopy Center for 2:00 PM or later, YOUR RIDE MUST REPORT TO THE CENTER DURING YOUR CHECK-IN PROCESS AND REMAIN AT THE FACILITY.
If your procedure is scheduled at McLean Surgical Center, your ride MUST REMAIN AT THE SURGICAL CENTER DURING YOUR PROCEDURE. THIS POLICY IS ENFORCED BY THE FACILITY AS WELL.
You should NOT operate any heavy machinery for at least 12 hours after receiving medication for sedation.

Initials

**PLEASE NOTIFY OUR OFFICE IF YOUR INSURANCE PLAN CHANGES BEFORE THE DATE OF YOUR PROCEDURE**

Patient Signature

Date

Advanced Digestive Care Representative

For staff use only

Date

For staff use only

NOTICE TO PATIENTS REGARDING OWNERSHIP INTEREST IN WOODBURN ENDOSCOPY CENTER, PLLC

I hereby acknowledge that Stafford S. Goldstein, M.D., Martin G. Prosky, M.D. and Srikrishna, Vemana , M.D ("Or. Goldstein/Prosky/Vemana"), who is involved in the provision of my ongoing medical care, has disclosed to me that (i) Dr. Goldstein/Prosky/Vemana have an ownership interest in Woodburn Endoscopy Center, PLLC; (ii) the endoscopic services that I will receive from Woodburn Endoscopy Center, PPLC, are available from other providers in the community; and (iii) I have the freedom of choice with respect to the selection of the entity or facility from which to obtain such professional services. I also acknowledge that Dr. Goldstein/Prosky/Vemana has advised me of the criteria of selection for the referral or recommendation of me to Woodburn Endoscopy Center, PLLC for professional services. I further acknowledge that this written notice was provided to me by Dr.Goldstein/Prosky/Vemana prior to the referral or recommendation to Woodburn Endoscopy Center, PPLC.

Patient Name / Signature

Date

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