"*" indicates required fields Step 1 of 9 11% This field is hidden when viewing the formDate MM slash DD slash YYYY Name* First Middle Initial Last Social Security Number*Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920*Patient SSN and DOB are needed to collect payment for healthcare services and to verify your identity when requesting and looking up health records.Are you under 45 years old?* Yes No Sex at Birth* Male Female Gender you Identify as***American Cancer Society recommends screenings at age 45. Please check your screening benefits to verify coverage.Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Race*Please Make a SelectionWhiteHispanicAsianAmerican IndianAlaska NativeBlack or African AmericanNative HawaiianPacific IslanderOtherEthnicity*Please Make a SelectionHispanic Or LatinoNot Hispanic or LatinoDeclinesMilitary*Please Make a SelectionYesNoMarital Status*Please Make a SelectionMarriedSingleDivorcedWidowEmployer*Work PhoneMobile Phone*Home PhoneMay DHP utilize text messaging to send information to you?* Yes. You consent/Opt-in to receiving SMS Messages. No. You Opt-out of receiving SMS messages. We will never share, trade, or otherwise sell your personal information such as Phone numbers and SMS consent to third parties under any circumstances.Email* Preferred Language*Primary Care Provider Name*Primary Care Provider LocationPrimary Care Provider Phone NumberPlease acknowledge that you have read and understood the below information:*As a Medical Office, we are required to provide all patients access to our Patient Portal and an electronic means to contact our office. I understand that I will be sent an email invitation to the Patient Portal and a text message invitation to download a HIPAA compliant texting application, pMD. I understand that I can use both of these options to conversate with the office. I understand This field is hidden when viewing the formWould you like to sign up for our patient portal using the email address provided above?**The Patient Portal at Digestive Health Partners allows you to communicate with our practice anytime using the internet. You can now pre-register, review your medical history, request appointments, send messages and review clinical results. Yes No Emergency Contact InformationName* First Last Relationship to Patient*Phone* Primary Insurance CoverageWill you be using our self-pay option?* Yes No Note: Self Pay patients will need to speak to a Financial Counselor prior to scheduling an appointment/procedure. Once form is completed, a Financial Counselor will contact you to discuss payment options.Primary Insurance Name*Medicare?* Yes No Name Displayed on Card*Plan ID*Group ID*Policy ID*Policy Holder Name*Policy Holders Relationship*Self, Spouse, Parent, OtherPolicy Holder Date of Birth* MM slash DD slash YYYY Policy Holders Employer*Secondary Insurance CoverageSecondary Insurance NameMedicare?* Yes No Name Displayed on CardPlan IDGroup IDPolicy IDPolicy Holders NamePolicy Holders RelationshipSelf, Spouse, Parent, OtherPolicy Holders Date of Birth MM slash DD slash YYYY Policy Holders EmployerTertiary Insurance Coverage (as needed)ListTertiary Insurance NameName Displayed on CardPlan IDGroup IDPolicy IDPolicy Holders NamePolicy Holders RelationshipPolicy Holders Date of BirthPolicy Holders Employer Add Remove Pre-Procedure Questionnaire**Height AND Weight MUST BE accurate. Patient BMI determines the most appropriate location for procedures. Procedures will be canceled upon arrival if BMI does not meet procedure center guidelines.Height - Feet*Please enter a number from 1 to 7.Height - Inches*Please enter a number from 0 to 11.Weight - Lbs*BMI - Filled AutomaticallyAre you prescribed blood thinner medication?*For example: Warfarin/Coumadin, Plavix/Clopidogrel, Lovenox/Enoxaparin, Xarelto/Rivaroxaban, Eliquis/Apixaban (This does not include Aspirin.) Yes No If you are currently prescribed a blood thinner, please provide the drug name below:*Please provide the Provider name and phone number of the Provider who prescribes and manages this medication:*Are you currently pregnant?* Yes No Have you delivered a baby in the last 6 months?* Yes No Are you currently breastfeeding?* Yes No Ever had any serious complications with Anesthesia, besides discomfort or nausea?* Yes No Have you ever been told by an Anesthesiologist that you have a difficult airway, or have had any intubation difficulties in the past?* Yes No Have you been given a letter by an Anesthesiologist stating you have a difficult airway?* Yes No Have you ever had a colonoscopy before?* Yes No Have you ever had any polyps removed?* Yes No With any previous procedure, did you have any significant problems?* Yes No If yes, please give location and date of last colonoscopy.*If yes, please list problems with previous procedures.*Are you diabetic?* Yes No Do you have any symptomatic, severe, uncontrolled heart, lung, or neurological disorders?*Examples would include recent heart surgery, stent placement in the last year, heart attacks in the last 6 months, recent chest pain, uncontrolled COPD, symptomatic congestive heart failure, Stroke, TIA or having sleep apnea requiring continuous oxygen of 2 liters or more. Yes No If yes, what was your last A1C reading?*What do your typical blood sugars run?*Are you insulin dependent?*Do you have a Cardiac Defibrillator?* Yes No Do you have an Abdominal Aortic Aneurysm greater than 4.0?* Yes No Have you had head or neck surgery since you were last seen at our office?* Yes No Are you currently being followed by a Neurologist/Cardiologist/Vascular/Lung Specialist?* Yes No If yes, please provide name and address of Physician.*Can you take care of yourself (eating dressing bathing or using the toilet)?* Yes No Can you walk indoors such as around your house?* Yes No Can you walk a block or two on level ground?* Yes No Can you climb a flight of stairs or walk up a hill?* Yes No Can you run a short distance?* Yes No Can you do light work around the house like dusting or washing dishes?* Yes No Can you do moderate work around the house like vacuuming, sweeping floors, or carrying in groceries?* Yes No Can you do yard work like raking leaves, weeding, or pushing a power mower?* Yes No Can you participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?* Yes No Can you participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?* Yes No Are you able to move your head up and down freely?* Yes No Are you able to move your head from side to side freely?* Yes No Do you use prescribed Oxygen 2 liters or more at a time?* Yes No Have you ever had any abdominal or GI Related Surgeries?* Yes No If yes, please list any abdominal or GI Related Surgeries.*Do you have any decreased kidney function?* Yes No Are you currently receiving Dialysis?* Yes No Are you on the Kidney Transplant list?* Yes No Have you ever had a heart and /or lung transplant?* Yes No Do you have narcolepsy?* Yes No Do you have a communicable disease such as TB or active infections?* Yes No If yes, do you take the medication Xyrem (Sodium Oxybate)?* Yes No Have you ever had a seizure?* Yes No Do you currently take any medications for seizures?* Yes No If yes, please list date of last seizure.*If yes, have you had a grand mal seizure in the last 6 months?* Yes No If yes, are they unstable or poorly controlled?* Yes No Have you tested positive for COVID-19?* Yes No Have you received the COVID-19 vaccine?* Yes No Date tested positive.*Please note you may not have procedure within 30 days of testing positive for COVID- 19 MM slash DD slash YYYY If yes, which vaccine did you receive and date of last dose.*Have you received the Flu vaccine?* Yes No If yes, when did you last receive this vaccine?*Have you recently had a fever, respiratory symptoms, cough, or shortness of breath?* Yes No Have you been treated for C-Diff and are now experiencing diarrhea?* Yes No Have you been diagnosed with diverticulitis and placed on antibiotics in the last 6 weeks?* Yes No Are you currently receiving Chemotherapy?* Yes No Do you have a port for IV or blood draw access?* Yes No Have you, on multiple occasions, required an Ultrasound to find your veins to place an IV or to have blood drawn?* Yes No Do you have an allergy to latex, or anaphylactic reactions?* Yes No Can you walk independently?* Yes No Do you ever require a wheelchair or a walker?* Yes No Can you weight bear and transfer yourself to a stretcher?* Yes No Do you use public transportation for appointments, such as Mtn Mobility?* Yes No Will you have a driver who can bring you to the procedure, stay with you for the duration, and then drive you home? This is required for all Endoscopy Procedures* Yes No Do you have your driver information available now?* Yes No Driver Acknowledgment* I acknowledge that I am required to have a driver the day of my procedure If you can't arrange for a driver, you can utilize the following approved transportation services here.Driver's Name* First Last Relationship*Mobile Phone* Previous ProceduresCheck all that apply.Previous Procedures* No Previous Procedures Ankle Surgery Appendectomy C-Section Cardiac Defibrillator Cardiac-Stent Placement Cervical Neck Fusion Cholecystectomy- Gallbladder Removal Colon Resection Coronary Artery Bypass Graft (CABG) - Heart Surgery Fundoplication-Nissen Gastric Bypass Surgery Head/Neck Surgery with Radiation Treatment Heart Valve Replacement Hiatal Hernia Repair Hip Replacement Hysterectomy Ileostomy Lung Lobectomy Lysis of Adhesions Mastectomy Medication Pump Nephrectomy- Kidney Removal NeuroStimulator Pacemaker Insertion PICC Line Port-A-Cath Prostate Surgery Shunt/Graft/Fistula Total Knee Replacement Tracheostomy Transplant- Heart Transplant- Liver Transplant- Lung Date of Appendectomy*Date of Cardiac Defibrillator*Date of C-Section*Date of Cardiac-Stent Placement*Date of Cervical Neck Fusion*Date of Cholecystectomy- Gallbladder Removal*Date of Coronary Artery Bypass Graft (CABG) - Heart Surgery*Date of Fundoplication-Nissen*Date of Gastric Bypass Surgery*Date of Head/Neck Surgery with Radiation Treatment*Date of Heart Valve Replacement*Date of Hiatal Hernia Repair*Date of Hysterectomy*Date of Ileostomy*Date of Lung Lobectomy*Date of Lysis of Adhesions*Date of Medication Pump*Date of Nephrectomy- Kidney Removal*Date of NeuroStimulator*Body Location of NeuroStimulator*Date of PICC Line*Date of Pacemaker Insertion*Date of Tracheostomy*Date of Port-A-Cath*Date of Prostrate Surgery*Date of Shunt/Graft/Fistula*Date of Transplant - Heart*Date of Transplant - Liver*Date of Transplant - Lung*Date of Ankle Surgery*Type of Ankle Surgery* Right Left Both Is there an arm that we must avoid for IV or blood draws?* Right Left N/A Date of Colon Resection*Reason For Colon Resection*Date of Hip Replacement*Type of Hip Replacement* Right Left Both Date of Mastectomy*Type of Mastectomy* Right Left Bilateral Date of Total Knee Replacement*Type of Total Knee Replacement* Right Left Both Other Previous Procedures Diagnostic Studies/TestsCheck all that apply.Diagnostic Studies/Tests* No Prior Diagnostic Studies/Tests Bravo pH Capsule Analysis Capsule Endoscopy Colonoscopy ERCP Esophageal Manometry Endoscopic Ultrasound (EUS) EGD Flexible Sigmoidoscopy Hep C Screening Liver Biopsy Percutaneous Date of Bravo pH Capsule Analysis*Date of Capsule Endoscopy*Date of Colonoscopy*Date of ERCP*Date of Esophageal Manometry*Date of Endoscopic Ultrasound (EUS)*Date of EGD*Date of Flexible Sigmoidoscopy*Date of Hep C Screening*Date of Liver Biopsy Percutaneous*Other Diagnostic Studies/TestsHistory of Procedure ComplicationsCheck all that apply.Procedure Complications* No History of Procedure Complications Difficult Airway/Intubation Anesthesia Complications Problems with Last Procedure Date of Difficult Airway/Intubation*Date of Anesthesia Complications*Date of Problems with Last Procedure*Other Procedure ComplicationsPast or Present Medical ConditionsCheck all that apply.Past/Present Medical Conditions* No Past or Present Medical Conditions Abdominal Aortic Aneurysm Adrenal Insufficiency (Addison's Disease) Anemia- Iron Deficiency Anxiety Disorder Aortic Stenosis Arthritis, Degenerative Arthritis, Rheumatoid Asthma Atrial Fibrillation Barrett’s Esophagus Bleeding Disorder, Prolonged Bleeding Blood Transfusion Breast Cancer Celiac Sprue Cervical Cancer Cirrhosis Colon Cancer Colon Polyps COPD COPD Requiring Oxygen Coronary Artery (Heart) Disease Crohn’s Disease Depression, Chronic Diabetes (Type I) Diabetes (Type II) Diverticulitis of Colon Diverticulosis Ehlers-Danlos Syndrome Emphysema Emphysema Requiring Oxygen Endometriosis Esophageal Cancer Familial Multiple Polyposis Syndrome Fatty Liver, Non-Alcoholic Gallstones Gastritis GERD Glaucoma H-Pylori Heart Attack Hemochromatosis Hepatitis A Hepatitis B Hepatitis C, Chronic Hiatal Hernia High blood pressure HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Inflammatory Bowel Disease Irritable Bowel Syndrome Ischemic Colitis Ischemic Vascular Disease Kidney Stones Leukemia, Chronic Limited Neck Range of Motion Liver Cancer Liver Disease Lung Cancer Lymphoma Lynch Syndrome Metal in Body Obesity Ovarian Cancer Pancreatitis, Acute Prostate Cancer Pulmonary Hypertension Radiation Therapy Rectal Cancer Renal Failure Syndrome Seizure Disorder Skin Cancer Sleep Apnea Sleep Apnea Requiring C-PAP Stroke Tuberculosis, History of Ulcer Disease Peptic Ulcerative Colitis Date of Abdominal Aortic Aneurysm*Date of Heart Attack*Location of Metal in Body*Date of Stroke*Radiation Therapy Location/Date*Other Medical Conditions Known Allergies and ReactionsCheck all that apply and describe the reaction.Allergies/Reactions* No Known Drug Allergies Adhesive Tape Codeine Sulfate Fentanyl Citrate Iodinated Contrast (IV Dye) Latex Morphine Penicillin Propofol Sulfa Versed Reaction to Adhesive Tape*Reaction to Codeine Sulfate*Reaction to Fentanyl Citrate*Reaction to Iodinated Contrast (IV Dye)*Reaction to Latex*Reaction to Morphine*Reaction to Penicillin*Reaction to Propofol*Reaction to Sulfa*Reaction to Versed*Other Known Allergies and ReactionsClick the + to add more allergies and reactions.Allergy ToReaction Add RemovePersonal MedicationsList of Current Medicines: List all tablets, patches, inhalers, drops, liquids, ointments, injections, etc. Include prescription, over-the-counter, Medical Marijuana, herbal including edibles for anxiety, vitamin, and diet supplement products. Also list any medicine you take only on occasion (like Viagra, nitroglycerin).No Medications No Personal MedicationsPersonal MedicationsClick the + to add your personal medications.Medication (Brand and Generic Name)Dose (Strength)How and how often you take the medicine? (By mouth, under your tongue, injection, etc.) Add RemoveConsent* Check here if you consent to importing of your medications from your pharmacy.*Pharmacy Name*Pharmacy Location*Pharmacy Phone Number Family HistoryCheck all that apply.Family History* No Known Family History Colon Cancer Colon Polyps Crohn's Disease Esophageal Cancer Gastric Cancer Liver Cancer Liver Disease Pancreatic Cancer Stomach Cancer Ulcerative Colitis Colon Cancer - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister, Son, Daughter)Age at Diagnosis Add RemoveColon Polyps - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveCrohn's Disease - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveEsophageal Cancer - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveGastric Cancer - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveLiver Cancer - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveLiver Disease - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemovePancreatic Cancer- Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveStomach Cancer - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveUlcerative Colitis - Further Information*Click the + to add more information.Relationship to Patient (Mother, Father, Grandparent, Brother, Sister)Age at Diagnosis Add RemoveSocial HistoryTobacco Use* Never Former Current - Some Use Current - Every Day Use Select all that apply* Chewing Tobacco Cigarettes Cigars Vape E-Cig/Vaping* Never Former Current - Some Use Current - Every Day Use Street/Illegal Drug Use* Never Former Current - Some Use Current - Every Day Use Anesthesia and sedation can have adverse and possible life-threatening reactions with illicit drug use, including marijuana. If currently using any illicit drugs or marijuana, please list name of drug.Alcohol Use* Never Former Current Number of Drinks per Day*Number of Drinks per Week* Consent Signature Typed Click here to type your name in lieu of signature. I certify that I have read and understand the questions asked within this form and have answered these to the best of my ability. I understand that a scheduler will be reviewing these again to ensure their accuracy at time of scheduling. I certify that if there are any changes after scheduling I will alert the Scheduling Department immediately, as this could change when my procedure can be scheduled.I certify that I have read and understand the questions asked within this form and have answered these to the best of my ability. I understand that a scheduler will be reviewing these again to ensure their accuracy at time of scheduling. I certify that if there are any changes after scheduling I will alert the Scheduling Department immediately, as this could change when my procedure can be scheduled.*I certify that I have read and understand the questions asked within this form and have answered these to the best of my ability. I understand that a scheduler will be reviewing these again to ensure their accuracy at time of scheduling. I certify that if there are any changes after scheduling I will alert the Scheduling Department immediately, as this could change when my procedure can be scheduled.*I acknowledge that I have read and understand the Cancellation policy and that failure to alert the office of my need to reschedule/cancel within the required time frame could result in a fee that must be paid prior to rescheduling my appointment. Review cancellation policy here.I acknowledge that I have read and understand the Cancellation policy and that failure to alert the office of my need to reschedule/cancel within the required time frame could result in a fee that must be paid prior to rescheduling my appointment.*I acknowledge that I have read and understand the Cancellation policy and that failure to alert the office of my need to reschedule/cancel within the required time frame could result in a fee that must be paid prior to rescheduling my appointment.*I acknowledge that I have read and understand the transportation policy for Endoscopy procedures. I also understand that in the event I do not have a driver for the procedure, AGA will supply me with an approved list of transportation services that will assist me with my procedure. I acknowledge that I must provide the name, relationship and contact number for my driver within 3 days of my procedure date. Review transportation policy here.I acknowledge that I have read and understand the transportation policy for Endoscopy procedures. I also understand that in the event I do not have a driver for the procedure, AGA will supply me with an approved list of transportation services that will assist me with my procedure. I acknowledge that I must provide the name, relationship and contact number for my driver within 3 days of my procedure date.*I acknowledge that I have read and understand the transportation policy for Endoscopy procedures. I also understand that in the event I do not have a driver for the procedure, AGA will supply me with an approved list of transportation services that will assist me with my procedure. I acknowledge that I must provide the name, relationship and contact number for my driver within 3 days of my procedure date.*I certify that I have been provided with the online link to begin viewing the written prep instructions for Endoscopy procedures. I understand that at the time of scheduling, a scheduler will be verbally reviewing with me all prep instructions for my procedure. I understand that I must take responsibility to ensure that I am prepping correctly for any scheduled procedure and failure to follow the prep as instructed could result in a same day cancellation and a fee may be assessed. Review prep instructions here.I certify that I have been provided with the online link to begin viewing the written prep instructions for Endoscopy procedures. I understand that at the time of scheduling, a scheduler will be verbally reviewing with me all prep instructions for my procedure. I understand that I must take responsibility to ensure that I am prepping correctly for any scheduled procedure and failure to follow the prep as instructed could result in a same day cancellation and a fee may be assessed.*I certify that I have been provided with the online link to begin viewing the written prep instructions for Endoscopy procedures. I understand that at the time of scheduling, a scheduler will be verbally reviewing with me all prep instructions for my procedure. I understand that I must take responsibility to ensure that I am prepping correctly for any scheduled procedure and failure to follow the prep as instructed could result in a same day cancellation and a fee may be assessed.* I understand that all Colonoscopy preps will be sent to an online pharmacy called GiftHealth. I understand that this is done at no extra charge to me and that prior to the procedure, I must contact them to set up delivery to my home. I understand that all required paperwork for this procedure will be provided to me when the Colonoscopy prep is delivered. Review here.I understand that all Colonoscopy preps will be sent to an online pharmacy called GiftHealth. I understand that this is done at no extra charge to me and that prior to the procedure, I must contact them to set up delivery to my home. I understand that all required paperwork for this procedure will be provided to me when the Colonoscopy prep is delivered.*I understand that all Colonoscopy preps will be sent to an online pharmacy called GiftHealth. I understand that this is done at no extra charge to me and that prior to the procedure, I must contact them to set up delivery to my home. I understand that all required paperwork for this procedure will be provided to me when the Colonoscopy prep is delivered.*I understand that all copayments/coinsurances/deductibles are required at time of service. I understand that I can speak to a Financial Counselor to discuss my payment options, if needed. I understand that it is my responsibility to pay any deductible amount, co-insurance or any other balance not paid for by my insurance company.I understand that all copayments/coinsurances/deductibles are required at time of service. I understand that I can speak to a Financial Counselor to discuss my payment options, if needed. I understand that it is my responsibility to pay any deductible amount, co-insurance or any other balance not paid for by my insurance company.*I understand that all copayments/coinsurances/deductibles are required at time of service. I understand that I can speak to a Financial Counselor to discuss my payment options, if needed. I understand that it is my responsibility to pay any deductible amount, co-insurance or any other balance not paid for by my insurance company.*This signature on file is my authorization for the release of information necessary to process my claim.This signature on file is my authorization for the release of information necessary to process my claim.*This signature on file is my authorization for the release of information necessary to process my claim.*UntitledFINANCIAL POLICY PAYMENT AT THE TIME OF SERVICE As a courtesy, we will bill your insurance for all billable services; however, you will be expected to pay any portion of your cost not covered by your insurance due to deductible, co-insurance, or co-payments on the day of service. SUBMISSION OF CLAIMS Your health insurance plan is a contract between you and your insurer. It is the patient’s responsibility to understand their insurance policy limitations. In the event your health insurance determines that they will not cover a service that you have received, you will be responsible for payment. Our business office can provide additional information and support for disputes and appeals. Please note - patient diagnosis cannot be changed on, added to, or deleted from a claim in order to facilitate better insurance coverage. OUTSTANDING BALANCES We urge you to keep your account current with our office. When an account balance becomes more than 90 days past due, it may be referred to an outside collection agency. At that time, any additional fees incurred will be the responsibility of the patient. If you need to make special payment arrangements, it is your responsibility to contact our business office before your account is sent to an agency. Minimum monthly payment arrangements may be made for no less than $50 per month, depending on the balance incurred. PAYMENT PLANS Only an approved, official, and signed payment plan document will stand as an acceptable payment agreement. Incremental payments made apart from an official payment plan will not be recognized as a payment arrangement between a patient and Asheville Gastroenterology Associates. OVERPAYMENTS In the event of an overpayment, our office will work to refund any applicable credits, minus any balances, as quickly as possible. RETURNED CHECKS, NSF, CLOSED ACCOUNTS Payments made to Asheville Gastroenterology Associates that are not honored by the bank will incur a returned check fee of $35.00.PAYMENT AT THE TIME OF SERVICE As a courtesy, we will bill your insurance for all billable services; however, you will be expected to pay any portion of your cost not covered by your insurance due to deductible, co-insurance, or co-payments on the day of service. SUBMISSION OF CLAIMS Your health insurance plan is a contract between you and your insurer. It is the patient’s responsibility to understand their insurance policy limitations. In the event your health insurance determines that they will not cover a service that you have received, you will be responsible for payment. Our business office can provide additional information and support for disputes and appeals. Please note - patient diagnosis cannot be changed on, added to, or deleted from a claim in order to facilitate better insurance coverage. OUTSTANDING BALANCES We urge you to keep your account current with our office. When an account balance becomes more than 90 days past due, it may be referred to an outside collection agency. At that time, any additional fees incurred will be the responsibility of the patient. If you need to make special payment arrangements, it is your responsibility to contact our business office before your account is sent to an agency. Minimum monthly payment arrangements may be made for no less than $50 per month, depending on the balance incurred. PAYMENT PLANS Only an approved, official, and signed payment plan document will stand as an acceptable payment agreement. Incremental payments made apart from an official payment plan will not be recognized as a payment arrangement between a patient and Asheville Gastroenterology Associates. OVERPAYMENTS In the event of an overpayment, our office will work to refund any applicable credits, minus any balances, as quickly as possible. RETURNED CHECKS, NSF, CLOSED ACCOUNTS Payments made to Asheville Gastroenterology Associates that are not honored by the bank will incur a returned check fee of $35.00.*PAYMENT AT THE TIME OF SERVICE As a courtesy, we will bill your insurance for all billable services; however, you will be expected to pay any portion of your cost not covered by your insurance due to deductible, co-insurance, or co-payments on the day of service. SUBMISSION OF CLAIMS Your health insurance plan is a contract between you and your insurer. It is the patient’s responsibility to understand their insurance policy limitations. In the event your health insurance determines that they will not cover a service that you have received, you will be responsible for payment. Our business office can provide additional information and support for disputes and appeals. Please note - patient diagnosis cannot be changed on, added to, or deleted from a claim in order to facilitate better insurance coverage. OUTSTANDING BALANCES We urge you to keep your account current with our office. When an account balance becomes more than 90 days past due, it may be referred to an outside collection agency. At that time, any additional fees incurred will be the responsibility of the patient. If you need to make special payment arrangements, it is your responsibility to contact our business office before your account is sent to an agency. Minimum monthly payment arrangements may be made for no less than $50 per month, depending on the balance incurred. PAYMENT PLANS Only an approved, official, and signed payment plan document will stand as an acceptable payment agreement. Incremental payments made apart from an official payment plan will not be recognized as a payment arrangement between a patient and Asheville Gastroenterology Associates. OVERPAYMENTS In the event of an overpayment, our office will work to refund any applicable credits, minus any balances, as quickly as possible. RETURNED CHECKS, NSF, CLOSED ACCOUNTS Payments made to Asheville Gastroenterology Associates that are not honored by the bank will incur a returned check fee of $35.00.*Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our notice before signing this consent and prior to any service being provided to you by the Practice. The Practice reserves the right to change the Notice of Privacy policies. If we change our notice, you may obtain a revised copy by sending a letter to the Practice's HIPAA Officer or by asking the provider's receptionist. You can also obtain a copy on the clinic's website at www.ashevillegastro.com. By signing this form, you acknowledge that you have been given an opportunity to read the clinic's Notice of Privacy Practices prior to any service being provided to you by this Practice, and you consent to the use and disclosure of your medical information to other healthcare providers involved in your care and for treatment, payment and healthcare operations. You have the right to revoke this consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH). I authorize Physicians/staff of DIGESTIVE HEALTH PARTNERS to release information pertaining to my condition and/or care to those individuals listed below:ListNameDOBRelationshipContact Phone Number Add RemoveDIGESTIVE HEALTH PARTNERS physicians/staff may contact me in the following manner: (check all that apply)Preferred Method of Contact (please check): Home Telephone Work Telephone Cell Number Patient Portal E-Mail Home TelephoneOK to leave message on machine with detailed message Yes Cell NumberOK to leave message on machine with detailed message Yes Work TelephonePatient Portal E-Mail: Signature of Patient/Legal RepresentativeDate MM slash DD slash YYYY If Legal Representative, relationship to PatientWE CANNOT SPEAK TO ANYONE YOU HAVE NOT LISTED ABOVE. THIS FORM MUST BE COMPLETED AND SIGNED.I hereby acknowledge that I can request a copy of this office’s Notice of Privacy Practices. Review here.I hereby acknowledge that I can request a copy of this office’s Notice of Privacy Practices.*I hereby acknowledge that I can request a copy of this office’s Notice of Privacy Practices.*List Add RemoveDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
