Gastroenterology Specialists of Delaware, LLC

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1 I, authorize, to discuss any aspects of my health including office visit arrangement, diagnosis and plan of care with Dr. George Benes/Dr. Michael J. Brooks and his staff. Patient Name: DOB: Print Full Name Signature of Patient: Date: Contact Information of Authorized Person: Name: Relationship to Patient: Phone: (Home); (Cell); (Work) Glasgow Medical Center 2600 Glasgow Avenue, #106 Newark, DE Phone: (302) Fax: (302)

2 GASTROENTEROLOGY SPECIALISTS OF DELAWARE LLC FINANCIAL POLICY Gastroenterology Specialists of Delaware, LLC are committed to providing you with the best care possible. If you have medical insurance, we are pleased to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. Payment for services is due at the time services are rendered. We accept cash, checks, MasterCard or Visa. We will be happy to process your insurance claim for reimbursement. Any such request must be initiated by completing an insurance form. In most instances, we accept assignment of insurance benefits. Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1.5% per month. Any past due balance 120 days old will be outsourced to an agency for collection and an administration fee of 35% of your balance due will be added to your total. Our office performs a large volume of Procedures, which require both considerable time and resources to perform. Please be considerate to your fellow patients and our office staff and allow 48 hours notice for cancellations. Our office reserves the right to charge patients a missed appointment fee for patients that do not provide us appropriate notification in cancelling an appointment. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract except we are contracted as preferred providers. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies to companies that pay a percentage (such as 50% or 80%) of U.C.R. which is defined as usual, customary, and reasonable by most companies. This statement does not apply to companies who reimburse based on arbitrary schedule of fees, which bears no relationship to the current standard and cost of care in this area. Not all services are covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We must emphasize that as medical providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility from the dates services are rendered. Therefore, it is often necessary for you to inquire and explore your benefits with your insurance carrier. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. In order for Gastroenterology Specialists of Delaware, LLC to provide the quality of care it offers, you must be willing to share in helping us to help you receive insurance benefits for which you are fully entitled. IF AT ANY TIME YOU ARE UNABLE TO PAY A BALANCE DUE, PLEASE CALL OUR OFFICE PROMPTLY TO MAKE A PAYMENT ARRANGEMENT. WE ARE HAPPY TO WORK WITH YOU. PATIENT NAME: DATE: SIGNATURE OF PATIENT, PARENT OR LEGAL GUARDIAN: DATE:

3 MEDICAL AND FAMILY HISTORY FORM TODAY S DATE: NAME: DATE OF BIRTH: MEDICATIONS: Please list all your current prescription and non-prescription medications, vitamins and supplements: None Dosage Medication How Many Times A Day? PAST MEDICAL HISTORY Acid Reflux Cirrhosis of Liver Groin Hernia Kidney Infection Polio Anemia Colon Cancer Heart Attack Kidney Stones Psoriasis Arthritis Colon Polyps Heart Failure Lupus Radiation Asthma Crohn s Disease Heart Murmur Migraines Rheumatic Fever Bleeding Disorder Depression Hepatitis Milk Intolerance Sciatica Blood Clots Diabetes Hiatal Hernia Multiple Sclerosis Seizures Blood Transfusion Diverticulitis High Blood Pressure Osteoporosis Sleep Apnea Cancer Duodenal Ulcer High Cholesterol Ovarian Cyst Stomach Ulcer Chest Pain/Angina Emphysema High Triglycerides Pancreatitis Stroke/ Paralysis Chronic Anxiety Fatty Liver HIV or AIDS Parkinson s Disease TB (Tuberculosis) Chronic Cough Gallstones Irregular Heart Beat Peptic Ulcer TB skin test + Chronic Lung Disease Glaucoma Irritable Bowel Syndrome Phlebitis Thyroid Disease Chronic Sinusitis Gout Kidney Disease/Failure Pneumonia Ulcerative Colitis ALLERGIES None Penicillin Sulfa Aspirin Iodine Latex Other 1 P a g e

4 SURGERIES/PROCEDURES None Colostomy Groin Hernia Hiatal Hernia Repair Obesity Surgery Thyroid Appendectomy C-Section Heart Bypass Hysterectomy Ovary Tonsillectomy Breast EGD Heart Stent Joint Replacement Prostate Tubal Ligation Colon Surgery ERCP Heart Valve Kidney Sigmoidoscopy Uterus Colonoscopy Gallbladder Hemorrhoids Liver Biopsy Stomach Other PREVIOUS HOSPITALIZATIONS Reason Date Reason Date FAMILY HISTORY Father Mother Grandparents Siblings Children Healthy Deceased Colon Polyps Colon Cancer Ulcer Disease Liver Disease Pancreas Disease Crohn s Disease Ulcerative Colitis Stomach Cancer Diabetes Mellitus Heart Attack Breast Cancer Other Cancer SOCIAL HISTORY Marital Status Married Single Divorced Widowed Occupation Unemployed Retired Smoking History Never Yes Packs per Day years Currently Smoking No Yes Other Tobacco Use No Yes Details: 2 P a g e

5 Alcohol Use No Yes Amounts per Day for years Drug Use No Yes Specify Drugs and Amounts Exercise None Yes How Much and How Often Hobbies None Yes Specify Recent Travel Outside US No Yes Where REVIEW OF SYSTEMS CHECK ALL THAT APPLY AT THE PRESENT TIME General Cardiovascular Genitoreproductive Male Fever or Chills Chest Pain or Tightness Discharge from Penis Loss of Appetite Rapid or Irregular Heart Beat Testicular Pain or Lump Weight Gain Shortness of Breath Weight Loss Swelling of Legs Gentitoreproductive - Female Weakness, Fatigue Varicose Veins Date of Last Period Gastrointestinal Respiratory Dermatologic Abdominal Distention Chronic Cough Rash or Hives Abdominal Pain/Cramping Wheezing Itching Belching Shortness of Breath Tattoos Black Stools Need for Oxygen Therapy Blood in Stool Change in Bowel Habits Urinary Neurologic Constipation Pain or Difficulty with Urination Numbness or Tingling Diarrhea Frequent Urination Dizziness Difficulty Swallowing Blood in Urine Lightheadedness Fat Intolerance Incontinence of Urine Vertigo Full After Eating Small Amounts Headaches Gas/Bloating Musculoskeletal Weakness in Arm Heartburn Stiff or Painful Joints Weakness in Legs Indigestion Swollen Joints Blurred Vision Hemorrhoids Back Pain Difficulty with Memory Jaundice Muscle Pain Nausea or Vomiting Pain with Swallowing Hematologic Psychiatric Poor Appetite Frequent Bruising Anxiety Rectal Bleeding Bleeding Does Not Stop Easily Depression Rectal Pain Regurgitation of Food Soiling/Incontinence Vomiting Blood Panic Attacks Tired Upon Waking AM 3 P a g e

6 Endocrine Immunizations Heat or Cold Intolerance Excessive Thirst or Urination Steroid Therapy (Prednisone) Hepatitis A Hepatitis B Other 4 P a g e

7 NOTICE OF PRIVACY PRACTICES GASTROENTEROLOGY SPECIALISTS OF DELAWARE LLC 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 The Health Insurance Portability & Accountability Act of 1996 ( HIPPA ) is a Federal Program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations. TREATMENT means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of this would include procedures such as a Colonoscopy or Endoscopy. We may telephone or fax medication prescriptions to a pharmacy. We may mail recall letters to you when it is time for a repeat procedure or office visit. We may contact PCP s offices to obtain referrals in order to facilitate pre-certification of procedures (if your insurance plan requires that we do so). PAYMENT means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. Examples of this would be sending a bill for your visit to the insurance company for payment. We may call your insurance company if they have denied payment for various reasons. 1 P a g e

8 HEALTH CARE OPERATIONS include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, costmanagement analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing as we are required to honor and abide by the written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer. The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or alternative locations. The right to amend your protected health care information. The right to inspect and copy your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. 2 P a g e

9 This notice is effective as of April 14, 2003, and we are required to abide by the terms of the NOTICE OF PRIVACY PRACTICES currently in effect. We reserve the right to change the terms of our NOTICE OF PRIVACY PRACTICES and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised NOTICE OF PRIVACY PRACTICES from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Right, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. Questions or concerns should be directed to: Gastroenterology Specialists of Delaware LLC Attn: Privacy Office 2600 Glasgow Avenue Suite 106 Newark, DE For HIPPA Information or to file a complaint: The U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue, SW Washington, DC Toll Free: I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPPA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly or indirectly. 3 P a g e

10 Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its NOTICE OF PRIVACY PRACTICES from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the NOTICE OF PRIVACY PRACTICES. I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name: PLEASE PRINT Relationship to Patient: Signature: Date: OFFICE USE ONLY I ATTEMPTED TO OBTAIN THE PATIENT S SIGNATURE IN ACKNOWLEDGEMENT ON THIS NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT, BUT WAS UNABLE TO DO SO AS DOCUMENTED BELOW: Date: Initials: Reason - 4 P a g e