Patient History, Gastro Care

Name *

Address *

City *

Zip *

Phone Number *

Email

Last 4 of SSN *

Date of Birth *

Primary Care Physician

Reason for Visit (List Symptoms) *

Pharmacy Name *

Pharmacy Phone Number *

Current Medications *

List any blood thinners (including aspirin)

Drug Allergies

Medical History

Surgical History

Gall Bladder
Appendix
Intestinal or colon surgery
Hysterectomy

Family History

Do you smoke? *

Yes
No

Years of Smoking

Packs per day

Do you drink alcohol? *

Last Colonoscopy

Location

Colonoscopy Findings

Last Endoscopy

Location

Endoscopy Findings

Last EUS or ERCP

Location

CT Scan

Location

Ultrasound Scan

Location

Primary Insurance

Member ID

Group #

Name of Insured

Relation to Patient

Secondary Insurance

Member ID

Group #

Name of Insured

Relation to Patient

Assignment of Insurance Information & Benefits/Release of Medical Information *

I hereby authorize Gastroenterology Care LLC to administer/perform any medical and or surgical procedure deemed necessary, and authorize release of information needed to secure payment. I authorize that all benefits by my insurance company be paid directly to Gastroenterology Care LLC. Furthermore, I understand that I am responsible for all co-pays/co-insurance/deductibles and/or charges incurred that are not covered in full by my insurance. I hereby authorize the release of all applicable medical information, including & without limitation, copies of all records and test results produced to the designated attending, referral, and/or follow-up physicians and such other health care practitioners or organizations who/which will be providing subsequent care or treatment in connection with care provided by Gastroenterology Care LLC.

E-Signature (Type Full Name) *

Today's Date *

H.I.P.A.A. CONSENT (Authorization to Release PHI)

To give consent to disclose health care information to someone OTHER than the patient, please write their name below: (ex: Family member, caretaker, close friend)

Name

Relation

Name

Relation

Name

Relation

Name

Relation

Select One *

YES, you may share relevant information with the listed individuals above.

I understand that signing this document means that Gastroenterology Care LLC may use and disclose my Personal Health Information (PHI) to help provide health care to me, to handle billing and payment, and to take care of other health care options.

Under the terms of consent, I can ask Gastroenterology Care LLC to restrict how my PHI is used or disclosed to carry out treatment, payment, or health care operations. I understand that Gastroenterology Care LLC does not have to agree with my request. If Gastroenterology Care LLC agrees, I understand that the agreed limits will be followed.

I understand that I have the right to cancel this consent, in writing or update of this form, at any time. If I do cancel this consent, I understand that Gastroenterology Care LLC may have already used or disclosed information about me and canceling this consent would not affect the information already used or disclosed.
NO, do not disclose my healthcare or billing information to family members or friends.

E-Signature (Type Full Name) *

Today's Date *

Notice of Privacy Practices