Microsoft word - new patient packet gmed

Pear M. Enam, MD, FACG • Rashid Hanif, MD, FACG • C.P. Choudari, MD, MRCP Office Information:
Your initial visit is for an office consultation only. The medical necessity of any other procedure such as
upper endoscopy, colonoscopy or other diagnostic test will be determined at the consultation. There is
no special preparation for this office visit. Please arrive 15 minutes early for your first appointment.
We are implementing an electronic medical record. Unfortunately, you may experience some delays. We
appreciate your patience as we work toward more efficient patient care.
Our office is located at:

Please bring the following with you to your office consultation:
Attached patient information, completed and signed prior to arrival. If paperwork is not
completed by your appointment time, your appointment will be rescheduled. Insurance, Medicare or Medical Assistance cards
Insurance referral form; if necessary. (Many primary physicians will not fax these.)
Medical records, if so instructed by your primary physician
Current medication containers / bottles
Your calendar, this will help you schedule a time for any testing / procedure the doctor may order.
Photo identification (in response to federally mandated standards). If your address differs from
that which is printed on your driver’s license or other photo ID, please bring a utility bill or
other correspondence that shows your name and correct address.

Co-payments and Medicare’s Co-insurance are collected on the date of service prior to your office visit. If
you are unable to make this payment, your appointment will be rescheduled.
After your initial visit, if you are having a medical problem or need assistance, we request that you call the
office between 8:00 a.m. and 3:30 p.m. It is very difficult for us to accommodate walk-in patients. Walk-
in patients may be charged a fee of $45.00 for a visit with the nurse.
Cancellations and rescheduled visits. Appointment times have been reserved for you. We request
that you cancel or reschedule your office appointment or endoscopic procedure by phone a minimum of 2
business days in advance. This will give us ample time to fill those appointments with patients who need
to be seen. There may be a charge of $25.00 for no show appointments and cancelled or rescheduled
appointments without proper notice. Failure to show up for an endoscopic procedure may result in a
charge of $75.00. This fee is not billable to your insurance company. Multiple cancellations,
reschedules or no show appointments may result in your discharge from our practice.
Please take a few minutes and visit our web site at: www.gidoc.biz. 11110 Medical Campus Road • Suite 250 • Hagerstown, MD 21742 Notice of Privacy Practices
To our patients. This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information: Use and disclosure of your health information in certain special circumstances The following circumstances may require us to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court or administrative order. 3. If required to do so by a law enforcement official. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement 8. For Workers Compensation and similar programs. Your rights regarding your health information 1. Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests. 2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Jean Gross, Office Manager. 4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Jean Gross, Office Manager. You must provide us with a reason that supports your request for amendment. 5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. 6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Jean Gross, Office Manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If you have any questions regarding this notice or our health information privacy policies, please contact Jean Gross, Office Manager, 301-733-4404. 11110 Medical Campus Road h Suite 250 h Hagerstown, MD 21742 h 301-733-4404 h Fax 301-733-3984 Pear M. Enam, MD, FACG • Rashid Hanif, MD, FACG • C.P. Choudari, MD, MRCP Patient Name: Last/First/Initial
Referring Doctor:
Primary Doctor:
Patient’s Phone #s:
Primary Insurance:
Second Insurance:
11110 Medical Campus Road • Suite 250 • Hagerstown, MD 21742 ASSIGNMENT AND RELEASE
I, the undersigned, have insurance coverage with: __________________________________________________________ and assign directly to Gastroenterology Associates medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges not covered by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic. _________________________________________ _______________ Signature of Insured/Guardian Date MEDICARE AUTHORIZATION
I request that payment of authorized Medicare benefits be made on my behalf to Gastroenterology Associates for any services furnished me by that physician. 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 or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes release of information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is only responsible for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. ___________________________________________ _____________ Medicare Subscriber Signature Pear M. Enam, MD, FACG • Rashid Hanif, MD, FACG • C.P. Choudari, MD, MRCP CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT
AND HEALTH CARE OPERATIONS
I, ________________________________ , hereby authorize Gastroenterology Associates to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Gastroenterology Associates can refuse to treat me. I have been informed that Gastroenterology Associates has prepared a notice ("Notice") that more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such Notice prior to signing this consent. I have been given a copy of the Notice for my records. I understand that I may revoke this consent at any time by notifying Gastroenterology Associates in writing, but if I revoke my consent, such revocation will not affect any actions that Gastroenterology Associates took before receiving my revocation. I understand that Gastroenterology Associates has reserved the right to change their privacy practices and that I can obtain such changed notice upon request. I understand that I have the right to request that Gastroenterology Associates restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that Gastroenterology Associates does not have to agree to such restrictions, but that once such restrictions are agreed to, they must adhere to such restrictions. ________________________________________ Signature of patient or patient’s representative (Form MUST be completed before signing.)

____________________________________________
Printed name of patient or patient’s representative
_____________________________________________ Relationship to the patient
11110 Medical Campus Road • Suite 250 • Hagerstown, MD 21742 Co-payment and/or co-insurance is due at the time of service. For your convenience we accept cash, Debit Cards, checks, VISA, MasterCardand Discover. Our office will submit claims for payment for office visits, in-patient hospital visits, endoscopic procedures and other medically related services to most insurance companies. We participate with many insurances and are contracted to accept their payment as payment in full. Co-payments, deductibles and services not covered by your insurance company are the responsibility of the patient. Please check with the receptionist regarding our participation with your insurance company. If we do not participate with your insurance company, we will submit the claims as a courtesy to you and will bill you for the balance. * HMO and Managed Care plans require referrals for services. If you do not have a valid referral on the day of your appointment, you will be asked to reschedule your appointment or pay for all charges at the time of service. * If a response is not received from the insurance company within sixty (60) days of billing, the balance will become the patient’s responsibility.
I understand and agree that I am ultimately responsible for the balance on my account for
professional services rendered since I, or my dependent, received the health care. I have
read, understand and agree to all the terms described in the Payment Policy above.
___________________
____________________
____________
Pear M. Enam, MD, FACG • Rashid Hanif, MD, FACG • C.P. Choudari, MD, MRCP Patient Name: _______________________________________ Today’s Date: ________________________
Race
___ White/Caucasian ___ Black or African American ___Asian ___Hispanic or Latino
___ American Indian or Alaska Native ___Native Hawaiian or Other Pacific Islander ___ Mixed ___ Other
___ Unknown ___ Patient declines to provide information
Ethnicity

___ Hispanic or Latino ___Not Hispanic or Latino ___Patient declines to provide information
Preferred Language

___ English

Contact Preference
___ Home phone / voice mail ___ Work phone / voice mail ___Cell phone / voice mail
Allergies

Current Medications

Medication
Medication
11110 Medical Campus Road • Suite 250 • Hagerstown, MD 21742
Diagnostic Studies / Tests

Previous Procedures - Please indicate any of the following procedures or surgeries you have had: NONE
Appendectomy – When:
Other procedures / surgeries not listed above:
Past or Present Medical Conditions
Please circle the conditions you currently experience or have had in the past:
Disease of Pancreas Emphysema Esophagitis
Social History
Marital Status: Single Married Divorced Separated Widowed Civil Union Unknown Other Pear M. Enam, MD, FACG • Rashid Hanif, MD, FACG • C.P. Choudari, MD, MRCP
Alcohol ___ None
Type

Caffeine ___None
Type

Tobacco
Smoking Status
___ Current every day smoker ___Current some day smoker ___ Former smoker ___Never smoker
___Smoker, current status unknown ___Unknown if ever smoked
Type

Drug Use ___None
___Used IV drugs in the past ___Used other drugs in the past ___Use recreational drugs now

Family Medical History ___No Knowledge of family history
Do you have a family history of: Celiac Sprue Yes / No
Diagnosis
FAMILY HISTORY
11110 Medical Campus Road • Suite 250 • Hagerstown, MD 21742 Review of Systems Do you experience any of the following?
CARDIOVASCULAR
GASTROINTESTINAL
MUSCULOSKELETAL
CONSTITUTIONAL
NEUROLOGICAL
EARS/NOSE/THROAT/MOUTH Y / N Vomiting
GENITOURINARY
PSYCHIATRIC
ENDOCRINE
HEMATOLOGIC/ LYMPHATIC
RESPIRATORY
Y / N Glaucoma

Pharmacy
Name:

If necessary, your medical information can be released to someone other than yourself. Please list names
of authorized people:

Spouse:__________________________________________________ _____Yes _____ No
Parent:________________________________________________
Other Names: (Please list relationship such as daughter, son, boyfriend, girlfriend, fiancé, sister, etc.)
___________________________________________________________________________________

Patient Signature - All information contained on these patient history forms is true and correct to the
best of my belief.
Signature:

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