I consent to have the following diagnostic examination performed by Dr. Goldstein, Dr. Prosky, or Dr. Vemana.
Notifier: Advanced Digestive Care, LLC
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.
G0121 or G0105
Screening coverage for Colonoscopies is only provided once every 10 years, if the patient is not in a higher risk category.
G. OPTIONS: Check only one box. We cannot choose a box for you.
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.
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
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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.
Procedure Cancellation/Rescheduling Policy: (Please initial to acknowledge the statements below.)
Transportation Policy: (Please initial to acknowledge the statements below.)
**PLEASE NOTIFY OUR OFFICE IF YOUR INSURANCE PLAN CHANGES BEFORE THE DATE OF YOUR PROCEDURE**
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.
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