Welcome to Texas Modern Gastroenterology!

Important Information:

We will call you within 72 hours for an appointment. If you have any urgent questions, please call us at 903-558-2222.

First Name:

Last Name:

Date of Birth:

Email address

Phone Number:

Home Address:

City:

State:

Zip Code:

What are you seeing the Gastroenterologist for?

Who is your Insurance Carrier? (Please note that we do NOT take Medicaid (Medicaid Traditional, Ambetter, Superior) plans as a Primary or Secondary Insurance*

What is your Subscriber Number? (Put Self Pay for Self Pay)

Please upload an image of the front of your insurance card:

Add file

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Please upload an image of the back of your insurance card:

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Do you have an HMO Insurance plan? PLEASE NOTE THAT IF YOU HAVE AN HMO INSURANCE, YOU WILL NEED A REFERRAL AUTHORIZATION SENT FROM YOUR PRMARY CARE PROVIDER TO YOUR INSURANCE COMPANY IN ORDER FOR YOUR VISIT WITH US TO BE COVERED BY YOUR INSURANCE.

YES

IF YES, PLEASE MAKE SURE YOU CONTACT YOUR PRIMARY DOCTOR'S OFFICE OR INSURANCE COMPANY AND MAKE SURE YOUR REFERRAL AUTHORIZATION IS COMPLETED BEFORE SEEING US. OTHERWISE, YOUR VISIT AND ALL TESTS MAY NOT BE COVERED BY YOUR INSURANCE, AND YOU WILL HAVE TO PAY OUT OF POCKET.

Do you have a supplemental insurance? Please list it below.

PLEASE NOTE THAT WE DO NOT TAKE MEDICAID (INCLUDING AMBETTER, SUPERIOR, TRADITIONAL MEDICAID) PLANS AS A PRIMARY OR SECONDARY INSURANCE PLAN

Please upload an image of the front of your secondary insurance card

Add file

Please upload a file

Please upload an image of the back of your secondary insurance card

Add file

Please upload a file

Who is your Primary Care Doctor?

Who is your Emergency Contact?

Emergency Contact Number?

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