Florida Digestive Specialists Gastroenterology and Liver Disease Management Over 30 Years of Service

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1 It is a pleasure to welcome you to Florida Digestive Specialists (Formerly Gastroenterology and Oncology Associates)! We strive to exceed your expectations and provide you with the best service possible. If you ever need assistance you are welcome to contact us at Appointments & Our Cancellation Policy: To schedule or change an appointment, please call If you need to miss your appointment, we ask that you notify us as early as possible or at least 24 hours in advance so that we can better serve our other patients. Any appointments not cancelled 24 hours in advance; you will be considered a "no show". Because cancellations adversely affect our ability to serve our patients appropriately, we charge $25.00 for any office visit appointments that are not cancelled or rescheduled with less than twenty four hours notice. This fee is not billable to your insurance company and will need to be paid prior to your next appointment. If you miss two appointments without cancelling or rescheduling with less than 24 hour s notice, or no show, it will require us to discharge you from the practice. Additionally, due to the amount of no show procedure (colonoscopy or upper endoscopy) appointments at the Bay Area Endoscopy Center, you will be charged $75.00 for a procedure appointment that is not cancelled or rescheduled within 72 hours of the procedure appointment. This fee is not billable to your insurance company and will need to be paid prior to your next appointment. If you miss two appointments without cancelling or rescheduling with less than 72 hours notice, or no show, it will require us to discharge you from the practice. Thank you for your cooperation! Patients Patients Signature: 1

2 PRESCRIPTION REFILL POLICY Currently our office receives a large volume of calls daily for medication refill request. Effective August 1 st, 2014, we have a new prescription refill policy. We understand that this is a change for both you and use therefore we hope to work together during this transition to ensure safe and high quality medical care. 1. Please bring all your prescription bottles/medication that you are currently taking to your appointment. This is important to make sure that you are taking the correct medications and the correct doses. We will continue to take the time to carefully review your medication and write any necessary refills at your office visit. We will also ask you to review the new prescription to make sure that they are written correctly. 2. We do require office visits on a regular basis for all of our patients taking prescription medications. The interval will vary depending on the type of medication prescribed. Please be sure you have enough medication to last until your next scheduled visit. 3. All prescription refill request should originate from the patient by contacting your local pharmacy to see if there are available refills. If no refills are available the Pharmacist will contact our office for a refill. All refill requests should be approved or disapproved by our office within 2 business days. 4. If you need a refill but are overdue for a follow up visit and or blood work (necessary for monitoring the safety or effectiveness of a medication), the provider may agree to call in enough medication to a local pharmacy to last until we are able to schedule an office visit. It is your responsibility to schedule an appointment before you run out of medication. You should schedule your next visit before you leave our office. 5. Please remember to advise our clinical staff if you are changing your local pharmacy; you are going on an extended vacation and need extra medication; if you will be using an out of town pharmacy while on vacation; and or changing to a new mail order pharmacy. This will allow us to ensure prescriptions are filled in a timely manner. 6. Prescription refills will only be handled during office hours Mon Fri, 8am to 5pm. No prescriptions will be filled during evenings and weekends. Please sign below acknowledging that you understand our policy. Patient Patient Signature: 2

3 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS I HEREBY AUTHORIZE to release information from my medical records, including information of a psychological, psychiatric and alcohol or drug related nature, HIV/AIDS: To: From: Date of Hospitalization: Patient s Printed Patient s Signature: Information Requested ( ) Discharge Summary ( ) History & Physical ( ) Operation Report(s) ( ) Pathology Report(s) ( ) X ray Report(s) & Film(s) ( ) Laboratory Report(s) ( ) Psychological Records ( ) Psychiatric Record (s) ( ) Alcohol/Drug Related ( ) AIDS/HIV Records ( ) Office Visit(s) ( ) All of the above ( ) Other DATED: This Day of, 2014 Witness : Patient: Witness : Relative or Legal Guardian *Authorization must be signed by the patient, or by the parents if patient is a minor; or by nearest relative or Court Appointed Guardian if patient is physically or mentally incompetent. 3

4 Welcome to Florida Digestive Specialists, P.A. Please read and sign our office policy regarding insurance and billing. We are preferred providers for many insurance companies. Please check with our office or consult your insurance handbook if you have questions. We will be happy to file with your insurance on your behalf. You will be responsible for all deductibles, copays, coinsurances at the time of service, in addition to any non covered services. We accept Medicare assignment and many HMOs. If you are a member of an HMO, you must obtain prior authorization for all services through your primary care physician. Patients without insurance coverage are expected to pay in full at the time of service, unless prior arrangements have been made with our office. All charges not paid by your insurance company are your responsibility. Please advise our office whenever you have a change of address, phone number or insurance coverage. I have read and fully understand the above financial policy. Patients Patients Signature: LIFETIME AUTHORIZATION DATE: I hereby authorize payment directly to the provider of the surgical/medical benefit. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration, or its intermediaries or carriers, or the billing agent of this physician, any information needed for this or a related insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of the medical insurance benefits to the provider. Patients Patients Signature: 4

5 CONFIDENTIALITY QUESTIONNAIRE PLEASE PRINT the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care options). Relationship: Home # ( ) Cell # ( ) Work # ( ) Relationship: Home # ( ) Cell # ( ) Work # ( ) Please list the family member or significant other, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY. Relationship: Home # ( ) Cell # ( ) Work # ( ) Relationship: Home # ( ) Cell # ( ) Work # ( ) May we leave a message on your answering machine/voice mail regarding your results or health care information? Yes No Please note that in an emergency or for the purpose of your care and when the medical information is directly relevant to that person s involvement with your care, we may disclose your medical information to family members, other relatives or close personal friends other than the above listed. P ATIENT NAME (please print): P atient/representative Signature: 5

6 PATIENT REGISTRATION FORM SCREENING COLONOSCOPY Patient Please circle Yes or No in answer to the following medical history questions. Do you have any allergies to medications and or Latex? YES / NO Please list any allergies: What medications are you currently taking? Please list any active medical problems: YES / NO Are you on Coumadin/(Warfarin Sodium), iron supplements (incl. vitamins), Lovenox, Plavix, Xarelto? (Please Circle) YES / NO On Oxygen or CPAP? YES / NO Currently infected with HIV or TB? YES / NO Had a coronary/vascular stent within the last year? YES / NO Had a heart attack or stroke in the last 6 months YES / NO Had intestinal surgery within the last 3 months YES / NO Problems with: sedation/anesthesia, opening your mouth, breathing tubes? YES / NO Are you on therapy for heartburn and/or other GERD symptoms? YES / NO Do you have chronic heartburn? (2 times or more per week) YES / NO Have you had an upper endoscopy in the past 30 days? If so, Where When YES / NO Do you see blood in your bowel movements? YES / NO Been hospitalized in the last month? If so Where When YES / NO Been Diagnosed with a known bleeding disorder or Anemia YES / NO Had heart pain (angina) or breathing problems in the last 3 months? YES / NO Had kidney failure? YES / NO Do you have frequent constipation or diarrhea? YES / NO Unexplained weight loss greater than 10 lbs. in the last month? YES / NO On chronic narcotic pain medicines? If so, how often? YES / NO Had heart valve surgery? YES / NO Do you have abdominal pain? Describe YES / NO Do you have a defibrillator/pacemaker or combination of both? YES / NO Personal history of Congestive Heart Failure (CHF), renal failure/insufficiency? YES / NO Had joint replacement in the last 6 months? YES / NO Had a colonoscopy previously? When? Where? YES / NO Do you weigh more than 350 pounds? YES / NO Do you have relatives with colon cancer/colon polyps? If so, Who? What? YES / NO Been diagnosed with diabetes and on insulin or oral diabetic medication? YES / NO Are you confined to a wheelchair? Please return this completed form to our office. If there are no contradictions, you will be assigned to one of our physicians to be set up for a colonoscopy. You may need a preliminary appointment, if there are medical concerns identified that would need attention before scheduling your colonoscopy. Your insurance company will be notified for benefit verification. 6

7 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information (PHI). 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 the treatment directly and indirectly Obtain payment from third-party payers Conduct normal healthcare operations such as quality assessments and physician certifications I received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. 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 to obtain a current copy of the Notice of Privacy Practices. Patient Name or Legal Guardian: Signature: PRACTICE USE ONLY I attempted to obtain the patient s signature in acknowledgement of the Notice of Privacy Practices Acknowledgement but was unable to do so as documented below: Initials: Reason: Florida Digestive Specialists 7 Revised

8 General/Constitutional: Appetite Reduced Fatigue Fever Night Sweats Weight Gain Weight Loss Allergy/Immunology: Seasonal Allergies HEENT/Neck: Change in Vision Loss of Hearing Hoarseness Mouth Sores Sore Throat Swollen Lymph Nodes Endocrine: Cold Intolerance Diabetes Heat Intolerance Respiratory: Asthma COPD/OSA (use of C-PAP machine) Cough Coughing up blood Shortness of Breath Wheezing Cardiovascular: Chest Pain Dyspnea on Exertion Orthopnea Palpitations PND (shortness of breath during sleep) Hematology: Blood Transfusion Abnormal Bleeding Anemia Easy Bruising Genitourinary: Passing Stool/Gas from Vagina Blood in Urine Erectile Dysfunction Urinating at night Pain with Urination Urinary Incontinence Vaginal Bleeding Musculoskeletal: Osteoporosis Swelling legs or feet or pale extremities Arthritis Bone Pain Muscle Aches Dermatologic: Itching Jaundice (yellowing of skin and/or eyes) Psoriasis Rash Skin Cancer Neurologic: Loss of Strength/Sensation Balance Difficulty Confusion Dizziness Headache Seizures Speech Abnormality Strokes Tingling/Numbness Gastrointestinal: Psychiatric: Abdominal Pain Black Stools Bloating Change in Bowel Habits Constipation Diarrhea Problem and/or pain with swallowing Feels full fast after eating Heartburn Vomiting blood Hemorrhoids Unintentional passing of Stool Nausea Pain when Swallowing Rectal Bleeding Vomiting Anxiety Depression Eating Disorder 8

9 Social History Patient These questions are only intended to assist in your healthcare. Please circle or check: Do you smoke cigarettes? No Yes Do you drink alcohol currently? No Yes If yes, how much do you drink? (1 serving=12oz beer, 5oz wine or 1.5oz liquor) please check: Occasional use-less than 3 servings per month Less than 7 servings per week More than 2 servings per day More than 7 servings per week If these do not apply, please indicate other amount: Servings per The following questions refer to recreational drug use: Have you ever snorted drugs (intranasal)? No Yes Have you ever used intravenous (IV) drugs? No Yes Have you used any drugs other than what s prescribed to you in the past 6 months? No Yes If yes, what did you use? 9