Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown)

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1 Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Patient Name: Date of Birth Mailing Address: City: State Zip: Apt/Ste/Unit/Bldg Primary Number: Alternate Number: Marital Status: Single Married Divorced Widowed Separated Sex: Male Female Social Sec. # EMERGENCY CONTACT: Name: Contact Number: Relation: Same Address Primary Care Physician: Referring Physician: Pharmacy Name & Phone: Tel. Tel. Tel. INSURANCE Name of Insurance: Name of Policy Holder: Policy Holder Soc: Name of Secondary Ins. Name of Policy Holder: Policy Holder Soc: Signature: Date of Birth: Relation to Patient: Date of Birth: Relation to Patient: Date: Office Check List Scanned Picture ID Scanned ID & Insurance Received Referral/Script/Authorization # Forms reviewed by: 1

2 Patient History Form Patient Name: Reason for today s visit PAST MEDICAL HISTORY Abdominal pain Heart disease Acid reflux/heartburn Hepatitis Anemia A B C Anxiety High blood pressure Bloating H-Pylori Blood in stool Liver disease: Cancer: Type Type Lupus Chest pain Mental illness Constipation Nausea/Vomiting Crohn's disease Pacemaker Defibrillator: Type: Type Pancreatitis Depression Polyp's Diabetes Rectal bleeding Diarrhea Shortness of breath Difficulty swallowing Tension Diverticulitis Tuberculosis: Epilepsy/Seizures When GERD Ulcer Heart burn Other Please list ANY serious illness in your family & who it pertains to: 1. Family: Surgeries/Hospitalizations 1. Date: / / 2. / / 3. / / Are you on ANY medications? ANY allergies to FOOD or MEDICATIONS? Do you smoke? How often Do you drink? How often Have you ever had a blood transfusion? When? Explain: 2

3 Authorization to Release or use Information for Treatment, Payment, or Health Care Operation I hereby authorize the releaser use of my individually identifiable health information ( protect health information ) and medical record information by Digestive & Liver Center of FL, P.A in order to carry out treatment, payment, or health care operations. You should review the Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing this Consent Form. We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes the terms of its Notice of Privacy Practices, you may obtain a copy of the revised Notice. You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the Practice. I acknowledge and agree that the Practice may disclose my protected health information and medical record information to the following individuals who are my family members, legal representatives, guardians, healthcare surrogates, or have power of attorney on my behalf: Name(s) of individual I agree that the Practice may also disclose the following types of information contained in my medical record (please initial the appropriate categories listed below): HIV/AIDS Information Mental Health Information Substance Abuse Information Sexually Transmitted Disease Information I agree and consent to the Practice releasing information to me in the following alternative manners (Please initial the appropriate spaces below): Via telephone, if I contact the Practice and provide the appropriate information (including my name, social security number and date of birth) Via regular mail with any envelopes being marked personal and confidential and addressed to me. Via fax to my designated fax number which is: At all times, you retain the right to revoke this consent. Such revocation must be submitted to the Practice in writing. The revocation shall be effective except to the extent that the Practice has already taken action based on the prior consent. The practice may refuse to treat you if you (or an authorized representative) do not sign this Consent Form. If you (or authorized representative) sign this Consent and then revoke it, the Practice has the right to refuse to provide further treatment to you as of the time of revocation (except to the extent that the Practice is required by law to treat individuals). I have read and understand the information in this consent. I HAVE RECEIVED A COPY of this consent and I am the patient or the authorized party to act on the behalf of the Patient to sign this document verifying consent to the above terms. Signature Please Name: Date: Relationship: 3

4 Digestive & Liver Center of FL, P.A. Financial Policy Please Read Carefully Digestive and Liver Center has a responsibility to provide quality healthcare services to patients. In the interest of maintaining a good doctor-patient relationship and continuing the delivery of quality healthcare, it is our hope that you will take responsibility for your financial obligation to our practice. The following are general policies we have established for our patients, which we believe allow the flexibility that some patients need. We encourage you to discuss your account, and any payment arrangements that you desire, with our office personnel. Discussion of these issues early on in your treatment process will prevent most concerns or misunderstandings. 1. INSURANCE As a courtesy to our patients, we will file claims on all visits and procedures, whether they are delivered in our office or the hospital. When we file a claim on your behalf, it is with understanding that benefits will be assigned to Digestive & Liver Center (that is, the insurance company will pay Digestive & Liver Center directly). You are responsible for payment of all deductibles, co-insurance and non-covered services. Please remember insurance coverage is a contract between the patient and the insurance company. The ultimate responsibility for understanding your insurance benefits and for payment to your doctor rests with you. 2. REFERRALS You are required to know whether or not your insurance requires a referral/authorization and obtain that referral/auth before you are scheduled to see our physicians. Our office will be happy to assist you in determining the status of any one of our doctors on your insurance plan; however, this is not a guarantee of coverage. You should take the time to call your insurance company to ask specifically about the doctor your wish to see and your covered benefits. Referrals typically have an expiration date and a limited number of visits so you should be careful to monitor the dates and visits. Our office will not see a patient who does not have a valid referral. 3. PROCEDURES - No Show for procedures and your account will be charged an administrative fee of $ APPOINTMENTS New Patient NO SHOW will be charged an administrative fee $ RETURNED CHECKS Your account will be charge $30 fee for each returned check. In addition, you will be asked to bring cash to our office to cover the returned check and the fee. 6. PAST DUE ACCOUNTS Patients who have not made an effort to make payment arrangements or have not expressed an interest in meeting their financial obligations to us, may be turned over to collection agency. Patients who have allowed their account to be turned to an agency will be expected to satisfy their financial obligation to us, and to pay for any future services in advance, before being seen by our physicians. 7. NON-COVERED SERVICES You have scheduled a visit with one of our physicians and that the physician believes to be relevant to evaluate, monitor and protect your health. However, Medicare and certain other insurance companies will only pay for services that they determine to be reasonable and necessary. If Medicare or another insurance determines that your visit with our physician or physician assistant is not reasonable and necessary, they will deny payment for that service. Sometimes insurance companies will not cover an office visit prior to a procedure when the patient comes to the doctor with no symptoms and is requesting a screening procedure. Denial of payments by your insurance company does not mean that you do not need to visit a physician or physician assistant beforehand. Our doctors recommend an office visit prior to the performance of any procedure, in order that the patient s general health may be evaluated and so that the patient is well informed about any recommended procedure. We are required to inform you that your insurance company may not cover the office visit and that you will be responsible for payment. PATENT STATEMENT ~ Benefit Assignment & Acknowledgement of Financial Responsibility~ I authorize the above named insurance companies to make payment directly to the Digestive & Liver Center of FL., P.A. for medical services I receive. I understand that I am financially responsible for payment of all non-covered services, co pay s, co insurance, deductibles and any other charge(s) my insurance company deems my responsibility. In the event my account should become delinquent for a period of thirty (30) days or more, I hereby acknowledge that I will be responsible for the entire balance, interest, court costs and/or attorney s fees involving the attempt to collect debt. Signature Date: 100 N. Dean Rd, Ste 101, Orlando FL Tel Fax

5 Advanced Beneficiary Notice NOTE: You need to make a choice about receiving these health care services. The purpose of this form is to help you make an informed choice about whether or not you want to receive our health care services, knowing that you may have to pay for them yourself. Discloser / Agreement Patient Name: Reason for Today s Visit: Date of Birth: Routine Preventive Exam: That is I have NO medical complaint or significant problem / abnormality that I am aware of ; If so please mark one of the following: Yes my insurance plan covers Preventive Medical Services No, my insurance plan does not cover Preventive Medical Services I don t know if my insurance plan cover Preventive Medical Services or I DO have a problem/complaint that I wish to have evaluated/treated by the doctor (describe below): My chief complaint is: I agree to pay for any and all services I received from the Doctors/providers of the Digestive & Liver Center of FL, that my insurance company refuses to pay, for what ever reason. This office will file a claim in my behalf, however if my insurance company refuses to pay for preventive medicine visits or my failure to (example non-covered services, plan does not pay for preventive medicine visits or my failure to secure a referral from my primary care physician ( I will pay the same upon written/verbal notice of their refusal). Failure to pay within 45 days of filing is for the purpose of this agreement, a refusal to pay. I further agree and understand that this office can only code and file a claim for my visit(s). With a diagnoses that was encountered and documented in my medical record. Thus, this office cannot comply with any request to improperly alter the medical record or claim for the purpose of securing payment from any insurance carrier which may be considered a fraudulent act(s). In the event I do not pay for these or any other services provided me when due, I agree to pay all cost of collection, including reasonable attorney fees, whether or not a lawsuit is commenced as part of the collection process. Signature Date: Print Name: 100 N. Dean Rd, Ste 101, Orlando FL Tel Fax

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