PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Address:

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1 NEW HAMPSHIRE GASTROENTEROLOGY, INC. 9 Washington Place, Suite 204, Bedford, NH Office: Fax: ** Please return this form completed ASAP** PATIENT INFORMATION Name: DOB: DATE: Home Address: Mailing Address if different: City: State: Zip: Phone: Cell Phone: _ Work phone: Referring Physician: Primary Physician: Address: Parent/Guardian Name: INSURANCE INFORMATION-(INCLUDE A COPY OF FRONT & BACK OF CARD(S) MEDICARE INSURANCE - PLEASE CIRCLE IF YOU HAVE PART A ONLY(HOSPITAL) OR PART A & B (HOSPITAL & DOCTOR) Primary Insurance: ID #: Insurance Address: Policy Holder (if other than patient): DOB: Relationship: Secondary Insurance: ID #: Insurance Address: Policy Holder (if other than patient): DOB: I hereby authorize payment of medical benefits billed to my insurance to: NH GASTROENTEROLOGY, INC. for services rendered to me. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I also accept responsibility for services provided in the event that my Health insurance coverage is not in effect at the time of service, the procedure is not a covered benefit under my insurance plan and I have not obtained the appropriate referral required by my health insurance plan and the coverage is denied or reduced as a result. I agree to pay all copayments at the time the service is rendered. I agree to pay all coinsurances and deductibles as required by my health care insurance. I give my permission to NH Gastroenterology, Inc. to speak to the following person(s) in regard to my medical information: Signature of patient or guardian DATE:

2 New Hampshire Gastroenterology, Inc. 9 Washington Place, Suite 204 Bedford, NH Tel: Fax: REVIEW OF SYSTEMS ***PLEASE RETURN THIS FORM COMPLETED ASAP*** Name: Date of birth: Date completed: (Please complete BOTH sides of this form. Fill out and check areas related to past and present health status and CARDIOVASCULAR Chest pain High blood pressure Murmur Pacemaker/AICD Heart surgery Irregular heart beat Heart valve Heart attack GASTROINTESTINAL Change in bowel habit Black stools Colitis Crohn s Disease Rectal bleeding Irritable bowel Colon polyps Colon cancer Diverticulosis Constipation Diarrhea Weight loss Ulcers Trouble swallowing Heartburn Hiatus Hernia Nausea Vomiting Stomach cancer Liver problems Hepatitis Pancreatitis Jaundice RESPIRATORY Asthma Emphysema Bronchitis Shortness of breath Wheezing Cough Pneumonia Tuberculosis Lung cancer NEUROLOGICAL Seizures Epilepsy Headaches Strokes ORTHOPEDIC Arthritis Joint replacement Pins, plates Gout Bone cancer EMOTIONAL Anxiety Schizophrenia Mental retardation Depression Manic Depressive OTHER MEDICAL PROBLEMS- Diabetes Thyroid Kidney disease MRSA Urinary incontinence Anemia Eye problems

3 New Hampshire Gastroenterology, Inc. 9 Washington Place, Suite 204 Bedford, NH Tel: Fax: MEDICAL HISTORY Primary Care Physician (PCP): Referring Physician: Medications please list prescriptions and over the counter medications below or attach separate sheet: Do you take a blood thinners such as COUMADIN/WARFARIN/PLAVIX? Do you have any allergies? Yes No If Yes, please list Are you allergic to latex? Yes No Surgical tape? Yes No Have you been hospitalized within the past year? Yes No If Yes, please list reason(s) why List surgical procedures within the last 10 years Have you ever had a colonoscopy? Yes No If Yes, please list when and physician Have you ever had a sigmoidoscopy? Yes No If Yes, please list when and physician Have you ever had an upper endoscopy? Yes No If Yes, please list when and physician Do you have a family history of colon cancer? Yes No If Yes, who Do you have a family history of colon polyps? Yes No If Yes, who Why are you having this procedure done? Have you been to this office or seen any of our physicians before? Yes No If Yes, who The following section must be completed: I give permission to NH Gastroenterology, Inc. to release information to the following people (example spouse, son, daughter): I give permission to NH Gastroenterology, Inc to release information for treatment, payment and health care operations. Patient signature Date ***PLEASE RETURN THIS FORM COMPLETEDTO OUR OFFICE AT LEAST 7 DAYS PRIOR TO YOUR PROCEDURE OR APPOINTMENT***

4 New Hampshire Gastroenterology, Inc 9 Washington Place, Suite 204 Bedford, NH Riverside Street, Suite 203 Nashua, NH Tel:(603) Fax: (603) Office Hours: M-TH 8:30am-5:00pm, F-8:00 am-4:30pm Dear, You have been scheduled for a(n): EGD Colonoscopy Ablation ERCP Manometry Office Visit Enclosed is information pertaining to your procedure / appt on Check in time: (this time could change due to facility schedule) Your appointment is scheduled at: * CMC- 100 McGregor St., Manchester, NH * BASC- Bedford Ambulatory Surgical Center -11 Washington Place, Bedford, NH * The the Rivers Edge- 185 Queen City Avenue, Manchester, NH * Office- 9 Washington Place, Bedford, NH OR 17 Riverside St., Ste. 203, Nashua, NH With Dr.Stuart Brogadir Dr.Mark Silversmith Dr. Christopher Dainiak Jessica Konopka, PA-C NOTE: There will be a $50.00 No Show or Late Cancellation Fee (less than 2 business days) for any office visit and $ No Show or Late Cancellation (less than 3 business days) for surgical procedures. Please return to our Bedford office the completed forms as soon as you receive them with a copy of your insurance card, front and back. Please follow your facility requirements listed below and bring a medication list with you on the day of your visit: CMC: Check in at the front desk and they will direct you to the Endoscopy Suite. BASC: Follow Online Patient Registration instructions at Use Patient Code: BASC603ENDO Questions: BASC: or Cust. Service: * RIVERS EDGE: Call at least one week prior to your appointment to Co-pays, deductibles and any co-insurance are the patient s responsibility. Patient is responsible for obtaining a referral as needed per individual plan. HIPAA the privacy policy is available at your request Bedford Ambulatory Surgical Center (BASC) patients Disclosure of Ownership Dr. Brogadir, Dr. Silversmith, and Dr. Dainiak maintain an ownership in this facility. You are not required to utilize this facility and may choose to have your procedure done elsewhere. The office will provide an alternative referral upon your request.

5 N.H. GASTROENTEROLOGY 9 Washington Place, Suite 204 Bedford, N.H CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS I,, hereby authorize N.H. Gastroenterology 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, N.H. Gastroenterology can refuse to treat me. I have been informed that N.H. Gastroenterology has prepared a notice ("Notice") which 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 understand that I may revoke this consent at any time by notifying N.H. Gastroenterology in writing, but if I revoke my consent, such revocation will not affect any actions that N.H. Gastroenterology took before receiving my revocation. I understand that N.H. Gastroenterology has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request. I understand that I have the right to request that N.H. Gastroenterology restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that N.H. Gastroenterology does not have to agree to such restrictions, but that once such restrictions are agreed to, N.H. Gastroenterology must adhere to such restrictions. Patient Name (please print) Patient Signature Date OR: Legal Representative, Parent or Legal Guardian Signature Date Relationship to Patient Authorization to Obtain Medical History By signing below, I hereby authorize NH Gastroenterology to obtain Medication History related to the patient above, from Community Pharmacies and /or Pharmacy Benefit Managers for the purpose of continued treatment. Patient Signature Date OR: Legal Representative, Parent, or Legal Gaurdian Signature Date

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