Patient Request Form - Gastroenterologist Folsom,CA-Reflux,Stomach Pain,Ulcers

PATIENT NAME:

First

Last

Date of Birth

Sex

Male
Female
Other

MAILING ADDRESS

Address Line 1

Address Line 2

City

State

Zip Code

HOME PHONE

WORK/CELL

PATIENT EMAIL

LANGUAGE

INTERPRETER NEEDED

YES
NO

REFERRING PHYSICIAN

REASON FOR REFERRAL

INSURANCE

PRIMARY CARE PROVIDER

CONFIDENTIAL PATIENT INFORMATION

Employer

Occupation

How Long

Business Phone

SPOUSES / GUARDIAN

Spouse/Guardian

DOB

Phone Number

INSURANCE INFORMATION

Medicare #

MediCal #

Insurance Company

Subscriber

ID #

Group #

Secondary Insurance

Subscriber

ID #

Group #

OTHER INFORMATION

Emergency Contact (other than spouse )

Address

Phone

Signature of Responsible Party *

Date

***The following Assignment of Benefits and Medical Records Release authorization is a necessary document in order for GASTROENTEROLOGY MEDICAL CLINIC to Bill for services rendered, and to receive payment directly from your insurance company.

PRIVATE AND GROUP INSURANCES

I assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including private insurance and other health plans to GASTROENTEROLOGY MEDICAL CLINIC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges that are not paid by insurance. I authorize GASTROENTEROLOGY MEDICAL CLINIC to release all information necessary to secure the payment.

Beneficiary Signature *

MEDICARE ASSIGNMENT AND AUTHORIZATION TO SUBMIT CLAIMS

I request that payment of authorized MEDICARE benefits be made on my behalf to GASTROENTEROLOGY MEDICAL CLINIC for any services furnished tome by any physicians associated with GASTROENTEROLOGY MEDICAL CLINIC.

I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.

I understand my signature requests that payment be made directly to a physician associate of GASTROENTEROLOGY MEDICAL CLINIC, and authorize release of medical information necessary to pay the claim. If other health insurances coverage is indicated in Item 9 of the HCFA - 1500 claim form (the Medicare insurance billing form) or elsewhere on other approved claim forms or on electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.

In MEDICARE assigned cases, GASTROENTEROLOGY MEDICAL CLINIC and/or its authorized agents, agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered services. Co-insurance and deductible are based on the charge determination of the MEDICARE carrier.

Beneficiary Signature *

Date

PATIENT HISTORY FORM

Sex

Male
Female

Have you had any relevant test pertaining to this problem? E. g. labs, X-rays?

List any current medications, strength, and dosage.

List any medication allergies. What reaction did you have?

List any previous surgeries that you have had.

Type Year Hospital City Surgeon

List any current medical problems or chronic illnesses

Problem Date Started Current Treatment

Have you been hospitalized for any reason other that surgery?

Reason Date Hospital City Physician

PATIENT HISTORY FORM

Habits

Cigarettes
Alcohol
Recreational drugs
Coffee, tea, sodas

Family History

Father

Known Illness/disease

Cause of death

Mother

Known Illness/disease

Cause of death

Brothers

Known Illness/disease

Cause of death

Sisters

Known Illness/disease

Cause of death

Other Relatives

Known Illness/disease

Cause of death

Social History

Do you have any children?

Yes
No

Are you under any stress?

Yes
No

Have you recently been camping or exposed to unusual food/water

Have you traveled outside the US?

Yes
No

Women only

At what age did you start menstruation?

Have you stopped?

Yes
no

Menstrual cycle is every

Duration of you period

Number of pregnancies

Number of Children

Number of miscarriages

Number of abortions

Explain any complications during pregnancy

Date of last pelvic exam

Pap smear

Results

Type of birth control pills used

Have you ever had venereal disease or syphilis?

Men only

Prostate or testicular disease?

Venereal disease?

Today's Date

PATIENT HISTORY FORM

Review of systems Do you have, or have you ever had in the past, any of the following? (mark with an X)

Skin

Itching or rash
Skin diseases

Allergy

Hay fever
Food allergies

Hematologic

Anemia
Bleeding Tendencies
Other blood diseases

Rheumatologic

Swollen joints
Aching muscles or joints
Gout
Lupus

Endocrine

Diabetes
Hyper or hypothyroidism
Adrenal disease

Psychiatric

Anxiety or depressions
Suicidal or homocidal ideas
Nervous breakdown
Psychiatric problems

DESIGNATION OF PERSONAL REPRESENTATIVE DESIGNEE FOR RELEASE OF INFORMATION

DESIGNATION SECTION

I, (print name) hereby designate the following person to receive information on my behalf as my personal representative/designee with respect to my health and financial information. *

Print Name of Representative/Designee (Designee can be a relative, spouse, child, parent, friend, etc.) *

Last four digits of Social Security Number:

The authority of this person when acting as my personal representative/designee is restricted the following functions:

This person is to be afforded all the privileges that would be afforded to me with respect to my health and financial information for all dates of service.

This person is to be afforded all the privileges that would be afforded to me with respect to my Health information only.

This person is to be afforded all the privileges that would be afforded to me with respect to my Financial information only.

This person is to be afforded all the privileges that would be afforded to me with respect to my health and financial information for only the following

Dates of service:

I understand that this designation does not expire until I revoke it in writing. I may revoke this designation at any time by signing the revocation section of my copy of this form and returning it to Gastroenterology Medical Clinic. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health and financial information have already acted in reliance on the designation.

Last four digits of Social Security Number:

Patient signature: *

REVOCATION SECTION

I hereby revoke this designation of a personal representative/designee.

Patient signature:

Date

TELEMEDICINE

What is Telemedicine?

Telemedicine (also sometimes called telehealth) services are a way to deliver healthcare services locally to a patient when the healthcare provider is located at a distant site. Telemedicine is generally defined as the use of electronic information and communications technology to exchange medical information from one site to another site to provide medical or surgical treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion or medical advice to, a patient.

When a healthcare provider believes a patient may benefit from the use of telemedicine services, telemedicine can maintain a continuity of care with the provider and facilitate patient self management and caregiver support of the patient. Telemedicine services often provides a broader access to medical care, eliminates transportation concerns, and increases comfort and familiarity for patients and their families when located in their own homes or other local environments.

However, telemedicine uses new communications technology for which there is little research supporting its effectiveness. For example, telemedicine services may not be as complete as in person healthcare services because the healthcare provider will not always be able to observe subtle non-verbal communications such as a patient's posture, facial expression, gestures, and tone of voice.

Telemedicine may transfer medical information through the use of interactive, real-time audio/visual technology (for example, video conferencing) or electronic data interchange (for example, computer-to-computer exchanges), or it may transfer medical information through the use of store-and-forward technology (for example, emails). While precautions are taken to secure the confidentiality of telemedicine services, the electronic transmission of medical information can be incomplete, lost or otherwise disrupted by technical failures. Additionally, despite such measures, the transmission and storage of medical information can be accessed by unauthorized persons, causing a breach of the patient's privacy.

I read and understand the information provided in this document. I discussed any question I had with my doctor and all of my questions were answered to my satisfaction.

Consent to Use Telemedicine

I am physically located in California. At the beginning of each telemedicine session, I will help my doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:

My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.
I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor’s staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
My doctor believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
If my doctor believes at any time that another form of services (for example, a traditional in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule an in-person consultation with my doctor or refer me to a healthcare provider in my area who can provide such services.
I have the right to withdraw consent to the use of telemedicine services at any time and receive in person healthcare services with my doctor.
I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.
I agree to have the necessary computer, equipment and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications.
The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “auto remember” usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.
No part of the encounter will be recorded without my written consent.
I have the right to access my medical information and obtain copies of my medical records in accordance with California law.
I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction.

Patient's Name *

Patient's Signature *

Date

FINANCIAL POLICY

Thank you for choosing Gastroenterology Medical Clinic as your gastrointestinal healthcare provider. Our goals are to provide you with excellent gastroenterology care, minimize your out of pocket expenses, and make paying your balance as easy as possible. Our financial department is dedicated to informing you, to the best of our ability, of your estimated portion of the changes for your care and assisting you with any billing questions you may have.

INSURANCE: For the convenience of the patient, we will file medical claims with insurance plans with which we have an agreement as valid insurance information is provided to us. It is the responsibility of the patient to make accurate and detailed insurance information available to us to enable the processing of his or her insurance claim. The patient is to be considered self-pay until this information is provided to us.

The patient is responsible for notifying our office of any insurance changes prior to scheduled appointments. Insurance policies are an agreement between the patient and his or her insurance company. All account balances are the responsibility of the patient. Payment is due from the patient upon receipt of the first statement from our office.

The patient is expected to know her or her insurance benefits to include deductible and co-payments. Co-payments are to be paid at the time of service. If the patient does not have medical insurance, or if Gastroenterology Medical Clinic providers are not participating with his or her insurance carrier, all charges incurred during treatment are due and payable at the time of service.

ALL CHECKS RETURNED FOR NON-SUFFICIENT FUNDS WILL BE ASSESSED A $25.00 CHARGE.

REFERRALS/AUTHORIZATIONS: It is the responsibility of the patient to obtain a referral from his or her primary care physician prior to the scheduled visit if a referral is required by insurance to obtain services provided by a specialty provider. if a referral is not obtained, the patient accepts full financial responsibility for all services rendered.

CANCELLATIONS/FEES: If the patient is unable to keep a scheduled appointment or procedure, it is his or her responsibility to notify our office at least 24-hours prior to the scheduled appointment, or 48-hours prior to the scheduled procedure. Appointments canceled after this time frame may be subject to a cancellation fee of $50.00. Additional fees may also be applied to requests for medical records and for physicians completing paperwork for patients (i.e Disability, FMLA forms). These fees are not covered by insurance, and the patient accepts full financial responsibility for all additional fees.

RELEASE OF INFORMATION: I hereby authorize Gastroenterology Medical Clinic to release information to my insurance company with regard to all treatment as is necessary to obtain payment for their services and to review activity related to the provider's participation as is necessary to obtain payment for their services and to review activity related to the provider's participation with my insurance plan. I assign all benefits, to which the patient or insured is entitled for my treatment and medical services provided to me, to be paid directly to Gastroenterology Medical Clinic. I accept financial responsibility for any and all charges incurred by me that are denied or not covered by my medical insurance. I acknowledge I am bound to pay to services rendered, including all costs of collection and reasonable legal fees should collection to become necessary. I have read and understand this Financial Policy, and by signing, I am in agreement and accept all terms and conditions described above.

Patient/Guardian Signature *

Date

New Patient Form

CONFIDENTIAL PATIENT INFORMATION

SPOUSES / GUARDIAN

INSURANCE INFORMATION

OTHER INFORMATION

PRIVATE AND GROUP INSURANCES

MEDICARE ASSIGNMENT AND AUTHORIZATION TO SUBMIT CLAIMS

PATIENT HISTORY FORM

PATIENT HISTORY FORM

Family History

Father

Mother

Brothers

Sisters

Other Relatives

Social History

Women only

Men only

PATIENT HISTORY FORM

REVOCATION SECTION

TELEMEDICINE

What is Telemedicine?

Consent to Use Telemedicine

FINANCIAL POLICY