Gastroenterology Stuart H. Coleman, M.D. David M. Dresner, M.D. James C. Strobel, M.D. Huey T. Nguyen, M.D. Abdul Jabbar, M.D. Steven P. Harrell, M.D. HEALTH PARTNERS Matthew D. McCollough, M.D. Emori B. Sizer, M.D. Dear Patient, Your primary care physician has referred you to our practice for a procedure. With this letter you will find patient registration, medical history, financial policy and procedure scheduling forms. Please complete the patient registration, medical history and procedure scheduling forms. Sign and date the patient registration, HIPAA and financial policy forms. (We will also need copies, front and back of your current insurance cards.) THESE FORMS WILL NEED TO BE RETURNED TO US IN ORDER TO GET YOUR PROCEDURE SCHEDULED. You may return them in the enclosed envelope, fax them to 812-949-5435 or email them to [email protected] . The completed information may also be brought to our office and you may sit down and schedule your appointment with our scheduling staff at that time. Please be aware the best time to stop in the office would be between the hours of 8:00am-4:45pm, Monday- Friday. If you have any questions concerning these forms, please feel free to call us at 812-945-0145. After receiving your information, a member of our scheduling staff will use the procedure scheduling form to coordinate your appointment time and instructions to prep for the procedure. Once the nurse has scheduled your appointment, she will mail you information with the date, time, location and instructions. She will include a prescription for the laxatives (for colonoscopies) to be taken to a local pharmacy. The scheduler's name and phone number will be listed on the bottom of your prep sheet if you have any questions concerning the procedure or need to reschedule. If you provided an email address you will receive an invitation to register for our "Patient Portal" once your appointment has been scheduled. Through the portal you will be able to communicate with us regarding, appointments, billing or clinical questions to your physician including results. **Once your appointment has been scheduled the insurance staff will check with your insurance company to verify benefits and check for precertification. You will be responsible for any deductibles, co-insurance or co-pays that have not been met.** If you have had any recent testing pertaining to your condition or symptoms, we will need copies of those. You may obtain a copy from your physician to give to us, or ask them to fax the records to us at 812-949-5435. It is very important we get all information requested and that you understand all your instructions. We will make every effort to make your visit as smooth and comfortable as possible. If you have any concerns, feel free to contact the office at 812-945-0145. For more information or directions visit us on the internet at www.ghpsi.com. Thank you for choosing our physicians to participate in your health care. Sincerely, Sammye Wright, CMM, CPC Office Manager 2630 6rant LiM Road, New Albany, IN &7150 {812} 945-0145 www.0hf._iSi.com
14
Embed
Gastroenterologyghpsi.com/docs/PROCEDURE PACKET FORM.pdf · gastroenterology patient demographic form dba gastroenterology of southern indiana 2630 grant line road, new albany, in
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Gastroenterology Stuart H. Coleman, M.D. David M. Dresner, M.D.
James C. Strobel, M.D. Huey T. Nguyen, M.D.
Abdul Jabbar, M.D. Steven P. Harrell, M.D.
HEALTH PARTNERS Matthew D. McCollough, M.D. Emori B. Sizer, M.D.
Dear Patient,
Your primary care physician has referred you to our practice for a procedure. With this letter you will find patient registration, medical history, financial policy and procedure scheduling forms. Please complete the patient registration, medical history and procedure scheduling forms. Sign and date the patient registration, HIPAA and financial policy forms. (We will also need copies, front and back of your current insurance cards.) THESE FORMS WILL NEED TO BE RETURNED TO US IN ORDER TO GET YOUR PROCEDURE SCHEDULED. You may return them in the enclosed envelope, fax them to 812-949-5435 or email them to [email protected] . The completed information may also be brought to our office and you may sit down and schedule your appointment with our scheduling staff at that time. Please be aware the best time to stop in the office would be between the hours of 8:00am-4:45pm, Monday- Friday. If you have any questions concerning these forms, please feel free to call us at 812-945-0145.
After receiving your information, a member of our scheduling staff will use the procedure scheduling form to coordinate your appointment time and instructions to prep for the procedure. Once the nurse has scheduled your appointment, she will mail you information with the date, time, location and instructions. She will include a prescription for the laxatives (for colonoscopies) to be taken to a local pharmacy. The scheduler's name and phone number will be listed on the bottom of your prep sheet if you have any questions concerning the procedure or need to reschedule.
If you provided an email address you will receive an invitation to register for our "Patient Portal" once your appointment has been scheduled. Through the portal you will be able to communicate with us regarding, appointments, billing or clinical questions to your physician including results.
**Once your appointment has been scheduled the insurance staff will check with your insurance company to verify benefits and check for precertification. You will be responsible for any deductibles, co-insurance or co-pays that have
not been met.**
If you have had any recent testing pertaining to your condition or symptoms, we will need copies of those. You may obtain a copy from your physician to give to us, or ask them to fax the records to us at 812-949-5435.
It is very important we get all information requested and that you understand all your instructions. We will make every effort to make your visit as smooth and comfortable as possible. If you have any concerns, feel free to contact the office at 812-945-0145. For more information or directions visit us on the internet at www.ghpsi.com.
Thank you for choosing our physicians to participate in your health care.
Sincerely,
Sammye Wright, CMM, CPC Office Manager
2630 6rant LiM Road, New Albany, IN &7150 {812} 945-0145 www.0hf._iSi.com
0 Prostate Cancer C) Psoriasis 0 Rheumatic 0 Seizures Fever
0 Sexually 0 Sleep apnea 0 Stroke or 0 TB or Positive Transmitted Paralysis TB Skin Test Disease
0 Thyroid Disease 0 Deep vein thrombosis
0 Pulmonary embolus (blood
0 CVA (stroke)
(blood dot In dot In lung) leg)
0T1A Other:
Immunizations 0 None
0 Au vaccine 0 Hepatitis A 0 Hepatitis B Q HPV 0 Meningococcal
0 Pneumoccocal 0 Tdap
Familr Medical History 0 No knowledge of family history
No family history of O Colon cancer 0 Colon Polyps
~
~ ~ .e
t) )o,. L Cl) .s:
~ G)
~ ~ 01
~ ;:, c: '0 0
E (i) Ill 0 (/)
Health StatUs
AQe/oa~ of Birth
Diagnoses
Family Hx of Colon cancer 0 0 0 0 0 0 Family Hx of Colon Polyps 0 0 0 0 0 0 Family Hx of Celiac Disease 0 0 0 0 0 0 Family Hx of Colitis 0 0 0 0 0 0 Family Hx of Crohn's Disease 0 0 0 0 0 0 Family Hx of Uver Disease 0 0 0 0 0 0 Family Hx of Breast Cancer 0 0 0 0 0 0 F"amlly Hx of Esophageal cancer 0 0 0 0 0 0
Your doctor referred you for a procedure because of what symptoms? ____ __
Please fill in all information listed below to assure your appointment is scheduled for your convenience and all major health issues are taken into consideration for safety of your preparation prior to the procedure.
YOU ARE SEDATED FOR THESE PROCEDURES AND WILL NEED SOMEONE TO DRIVE YOU HOME AFTERWARD.
Please choose from our physicians listed below to perform the procedure: Stuart Coleman David Dresner James Strobel __ __ Huey Nguyen__ Abdul Jab bar Steven Harrell __ Matthew McCollough Emori Bizer No preference __
Schedule procedure on: Monday Tuesday Wednesday Thursday Friday Any
Is there any specific date(s) good for you? ________________ _
Is there any specific date(s) NOT good for you? ______________ _
Are you allergic to latex? __yes _no Are you a diabetic? __yes no Ifyes, controlled by: diet
__ medicine -please list name and dosage __________ _ __ insulin- dosage __________________ _
Please list any medications for: Arthritis __yes _none Heart disease __yes _none Blood thinner __yes _none Date started: -------Do you have an artificial heart valve? __yes _no Date of surgery: _______ _ Type of valve: __ Mitral Aortic If yes, do you receive antibiotics prior to dental work or surgery? _yes no Do you have a pacemaker? _yes _no Date of placement:---------If yes, list brand and model. ___________________ _ Have you had stent placement during heart surgery? _yes _no Date of surgery: ____ _ Do you have a personal history of cancer? _______________ _
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
GASTROENTEROLOGY HEALTH PARTNERS, PLLC
d/b/a/ GASTROENTEROLOGY OF SOUTHERN INDIANA, PC
GASTROENTEROLOGY HEALTH PARTNERS, PLLC reserves the right to modify the privacy practices outlined in
the notice.
Signature
I have received a copy of the "Notice of Privacy Practices" for GASTROENTEROLOGY HEALTH PARTNERS, PLLC.
Name of Patient {Print or Type)
Signature of Patient
Date
Signature of Patient Representative (Required if the patient is a minor or an adult who is unable to sign this form)
Relationship of Patient Representative to Patient
This notice is effective on or after July 1, 2013.
STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Information to be Used or Disclosed
The information covered by this authorization includes:
Purposes of Disclosure
Information listed above will be disclosed for the following purposes:
Persons Authorized to Use or Disclose Information
Information listed above will be used or disclosed by:
Name of person/organization
Name of person/organization
Name of person/organization
Persons to Whom Information May Be Disclosed
Name of person/organization
Name of person/organization
Name of person/organization
Expiration Date of Authorization
This authorization is effective through__} _/20_ unless revoked or terminated earlier by the patient or
the patient's personal representative.
Right To Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to Gastroenterology Health
Partners, PLLC. You should contact the HIPAA Privacy Officer to terminate this authorization.
This notice is effective on or after July 1, 2013.
NOTICE OF PRIVACY PRACTICES
GASTROENTEROLOGY HEALTH PARTNERS, PLLC
d/b/a/ GASTROENTEROLOGY OF SOUTHERN INDIANA, PC
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for
the purpose of evaluating your health, diagnosing medical conditions and providing treatment. For example, results of
laboratory tests and procedures will be available in your medical record to all health professionals who may provide
treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage
such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your
health plan may request and receive information on dates of service, the services provided, and the medical condition
being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and
management of Gastroenterology Health Partners. For example, information on the services you received may be used
to support budgeting and financial reporting, and activities to evaluat~ and promote quality.
Law Enforcement. Your health information may be discussed to law enforcement agencies to support government
audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated
reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For
example, we are required to report certain communicable diseases to the state's public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose
other than those listed above requires your specific written authorization. If you change your mind after authorizing a
use or disclosure of your information you may submit a written revocation of the authorization. However, your decision
to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified
us of your decision to revoke your authorization.
Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to send you appointment reminders.
Information about treatments. Your health information may be used to send you information that you may find
interesting on the treatment and management of your medical condition. We may also send you information describing
other health-related products and services that we believe may interest you.
This notice is effective on or after July 1, 2013.
Fundraising. Unless you request us not to, we will use your name and address to support our fundraising efforts. If you
do not want to participate in fund raising efforts, please check off the following box.
o Please do not use my information for fundraising purposes.
Individual Rights
You have certain rights under the federal privacy standards. These include:
• The right to request restrictions on the use and disclosure of your protected health information
• The right to receive confidential communications concerning your medical condition and treatment
• The right to inspect and copy your protected health information
• The right to amend or submit corrections to your protected health information
• The right to receive an accounting of how and to whom your protected health information has been disclosed
• The right to receive a printed copy of this notice
Gastroenterology Health Partners. PLLC Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this
"Notice of Privacy Practices".
We also are required by abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our
policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will
provide you with the most recently revised notice on any office visit. These revised policies and practices will be applied
to all protected health information we maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted by federal
regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may
obtain a form to request access to your records by contacting our Office Manager, Sammye Wright, or Laurie Streib, our
HIPAA Privacy Officer. Your request will be reviewed and will be generally approved unless there are legal or medical
reasons to deny the request.
Complaints and Contact Information
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter
outlining your concerns to:
Laurie Streib, HIPM Privacy Officer
Gastroenterology Health Partners, PLLC
2630 Grant Line Road
New Albany, IN 47150
This notice is effective on or after July 1, 2013.
GASTRO~NTEROLOGY OF SOUTHERN INDIA.NA, P.C.
PATIENT FINANCIAL POLICY
Thank you for choosing us as your health care prov!der. We are committed to providing you with the best possible care and to your treatment being succesSful. ·Your clear understanding of our financial policy is important to our professional relationship. Please understand that payment of your bill is considered part of your treatment. we accept Casti, Check, Money Order, Visa, Mastercard and Discover. · · ·
INSURANCE
Our practice is committed to providing the best treatment for our patients. We must emphasize that as Medical care provider~, our relationship is with you, our patient, not with your insurance company. We cannot accept the responsibility of negotiating the claims with insurance companies or any other persons. While the filing of insurance claims is a "courtesyn that we extend to our patients, all charges are your responsibility· from the date of the services rendered.
Your insurance coverage is a contract between you and your insurance company. It is very important that you understand the provisions. of your policy. We cannot guarantee payment of claims. If your Insurance company pays only a portion of the bill or rejects your claim, any contact or explanation shou·ld be made to you, their policyholder. Reduction or rejection of your claim by your insurance company does not relieve you of your financial obligation.
Not all services are a covered benefit In all contracts. Some insurance companies arbitrarily ·select certain services they will not cover. Some of the services may be considered ."non-coveredn services and not considered necessary under Medicare and other medical insurance programs. Please remember that prOfessional services are rendered and charged to the patient, not the insurance company.
We charge what is usual and customary for our area. The patient is responsible for payment in full within a reasonable time - regardless of the status of the claim or any insurance company's arbitrary determination of usual and customary rates. Our fees are considered to fall within the acceptable range of most companies and therefore are covered up to the maximum allowance determined by each carrier.
If you have a managed care medical Insurance that we participate with, your payment of deductibles, non-covered services and co-payments are due when services are rendered. If we do not participate with your insurance company or if you do not have health insurance coverage, payment in full for services is due at the time· services are rendered.
Although an insurance claim is filed, you will receive. a monthly statement if your account has a balance due. This office cannot accept responsibility for collecting your insurance claim or for negotiating a settlement on a disputed claim. The patient is responsible for payment.
If you would have a procedure by any one of our physicians at Southern Indiana Endoscopy, LLC, (SIE) our ambulatory surgical center, you will receive a bill from SIE for ·a facility fee and GSI for a physlcian's.fee and pathology, if any.
In the event that you ca.nnot pay your balance in full, we e,ncourage you to contact our financial department for assistance In the management of your account. If your account becomes delinquent and you have not responded to our collection efforts, your account may be turned over to an outside source for collecting the balance due,.and at which time you will be responsible for all fe~s related to that expense.· Failure to respond to collection efforts may result ·in your dismissal from our practice.
COMMUNICATIONS REGARDING MY ACCOUNTS
Until my accounts are finally settled, I give my direct consent to receive communications regarding my accounts from any servicers and any collectors of my accounts, through various means such as 1) any cell, landline or text number that I provide, 2) any email address that I provide, 3) auto dialer systems, 4) volcemail messages and other forms or communications.
RETURNED CHECKS
Any returned checks are subject to a $35.00 service fee. Any returned check must be resolved before any future appointments can be arranged.
Patient Financial Policy Page 2
MISSED/RESCHEDULED APPOINTMENT POLICY (Effective November 1, 2009)
We make every effort to strive for excellence in our specialty and in our profession. An important aspect of providing quality care is to be respectful of your time and make every attempt to accommodate your scheduling needs. To accomplish this, it is very important to be on time for your appointment, arriving early for paperwork, and to notify us In the event you need to reschedule this appointment. We reserve an ample amount of time for our patients because we feel it Is important In providing quality health care. Therefore, sufficient notice to change your appointment is necessary in order to accommodate your needs and to have the opportunity to offer this time to another patient.
Due to the increasing number of "no show" patients, we have made the difficult decision to assess a "no show" fee to patients who simply do not show for a previously scheduled appointment. We greatly appreciate your consideration in calling us at least 2 business days prior to your scheduled appointment for any cancellations or rescheduling needs. Appointments that are not cancel/edfrescheduled by 1.2:00 noon the day prior to your appointment will incur a $25.00 charge. It is our sincere hope that this will not be necessary.
Please Note: This charge is not covered or paid by any insurance company; therefore, the charge will be billed directly to the patient. This fee must be paid prior to being seen for any rescheduled appointments. To reschedule or cancel an appointment, please call our appointment line directly, (812) 206-7090. If the appointment scheduler Is with a patient, please feel free to leave a message on her voice mall. Your call will be promptly returned If necessary.
MINOR AGE PATIENTS
For unaccompanied minors, treatment will be denied unless charges have been pre-authorized prior to date of service. The adult accompanying a minor and the parents or guardians are responsible for payment In full.
MEDICARE, MEDICAID, PRIVATE INSURANCES
If you are covered by one of the above, or any other government sponsored program, you must present your current insurance card prior to services being rendered. If your card is not available, we will be happy to reschedule your appointment.
WORKMAN'S COMPENSATION, AUTOMOBILE ACCIDENTS
If you are covered by one of the above, we do not file on these services and payment in full is due at time of service, although we will provide you with any information that you may need to file for these services on your own.
FMLA/DISABILITY FORMS (Effective November 1, 2009)
Gastroenterology of Southern Indiana, P.C. will charge $35.00 for each FMLA and/or disability form we complete. These fees must be paid prior to the forms being complete.
Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.
1 have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice.