Amarillo Endoscopy Center Srinivas Pathapati, MD., PA 6833 Plum Creek Drive Amarillo, TX (806)

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1 Today s Date: / / PATIENT INFORMATION Patient s Last Name First Middle Mr. Miss Mrs. Ms. Marital Status (Circle one) Single / Mar / Div / Sep / Widow Legal Name (If applicable) Maiden Name Birth Date Age Sex Social Security Home Phone Cell Phone Street Address/P.O. Box City State Zip Code Employer Employer Phone No. IN CASE OF EMERGENCY Name of Local Friend or Relative (not living at same address) Relationship to Patient Home Phone No. Work Phone No. INSURANCE Primary Insurance Company A copy of your insurance cards will be obtained. If unavailable, you will be asked to provide more information. Subscriber s Name Subscriber s S.S.# Birthdate Name of Secondary Insurance PHARMACY Please lit below the Pharmacy you would like us to use: Mail In Pharmacy Phone#( ) Phone#( ) PATIENT PORTAL ADDRESS:

2 PERMISSION TO LEAVE RESULTS In the event there is lab, pathology results, or post procedure follow-up calls from the physicians, or his staff, please specify how this office may leave messages. (example: Machine or designated relative). I give my permission for this office/clinic to leave lab, pathology results, or post procedure follow-up calls as follows: Please circle MYSELF ONLY SPOUSE ANYONE WHO ANSWERS THE TELEPHONE ANSWERING MACHINE OTHER CONSENT TO TREATMENT I hereby voluntarily consent to outpatient care by Amit K. Trehan, M.D./Srinivas Pathapati, M.D. encompassing routine diagnostic procedures, examinations and medical treatment including (but not limited to routine laboratory work (such as blood, urine, and other studies), taking x-rays, heart tracings, and administration of medications). ASSIGNMENT OF BENEFITS AUTHORIZATION. RELEASE OF LIABILITY I hereby authorize the release of any medical information including the diagnosis and the treatment or examination rendered to me during the period of such care to third (3 rd ) party payer to process this claim and / or other health practitioners. Moreover, I authorize the holder of my medical records to release a CMS/Centers for Medicare & Medicaid Services and its agents any information to determine these benefits payable for related services. I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize and request Medicare or other insurance company benefits by made on my behalf directly to the doctor or doctors group, otherwise payable to me for any services furnished by them. I further understand that my insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Moreover, I agree to pay for nay services that are rendered if my insurance denies them for any reason. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/PATIENT BILL OF RIGHTS I acknowledge that I understand the Notice of Privacy Practices/Patient Bill of Rights from the offices of Amit,K. Trehan, M.D., And Srinivas Pathapati, M.D., or the Amarillo Endoscopy Center. PATIENT SIGNATURE Patient Signature Date Name of Office Representative Date Placed in Patient Chart

3 DATE: REFERRING PHYSICIAN: REASON FOR CONULTATION:1. PAST MEDICAL HISTORY: (check all that apply) Hypertension Heart Disease High Cholesterol Stroke Seizures Depression Diabetes Thyroid Disease Asthma/Emphysema/Bronchitis Cancer: a. Colon b. Lung c. Prostate d. Breast e. Others PAST SURGERIES: CURRENT MEDICATIONS: DRUG ALLERGIES SOCIAL HISTORY: Tobacco use Yes number packs per week? No. of years? No Alcohol use Yes What type? How much? No FAMILY HISTORY: Colon Cancer Colitis Peptic Ulcer Disease Liver Disease Other GI Problems

4 FINANCIAL POLICY We are doing everything possible to hold down the cost of medical care. You can help a great deal by reducing the number of bills we send to you. The following is a summary of our payment policy. ALL Co-Pays are EXPECTED AT THE TIME OF SERVICE. If you do not have your copay we will reschedule your appointment. Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and copayments for participating insurance companies. We accept cash, personal checks (in-state only), VISA, MasterCard, Discover, American Express and Care Credit. There is a $35 service charge for returned checks. Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments. We realize that financial difficulty is a reality. INSURANCE: We bill insurance companies as a courtesy to you. You are expected to pay your deductible and copayments at the time of service. If we have not received payment from your insurance company within 60 days of the date of service, you may be expected to pay the balance in full. You are responsible to ensure all charges are paid either by you or by your insurance carrier. If you need assistance or have questions, please contact The Billing Office between 8:30 a.m. and 5:00 p.m., Monday through Friday at REFUNDS: Patient/guarantor credits in amounts less than $20 will be retained on account to be credited toward future balances unless a written request for refund is received. Amounts of $20 and greater will automatically be refunded to the patient/guarantor. MANAGED CARE: If you are enrolled in a managed care insurance (i.e., HMO), you must have a referral from your primary physician in order to see us as we are a Specialist. MISSED APPOINTMENTS/LATE CANCELLATIONS: Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or late-canceled appointments. Excessive abuse of scheduled appointments may result in discharge from the practice. If it becomes necessary to forward your account to a collection agency, in addition to the amount owed, you also will be responsible for the fee charged by the collection agency for costs of collections.

5 PATIENT BILL OF RIGHTS Dr. Amit Trehan and Dr. Srinivas Pathapati have established this Patient s Bill of Rights as a policy with the expectation that observance of these rights will contribute to more effective patient care and greater satisfaction for the patient, his physician, and the group organization. It is recognized that a personal relationship between the physician and the patient is essential for the provision of proper medical care. The traditional physician-patient relationship takes on a new dimension when care is rendered within an organizational structure. Legal precedence has established that the facility itself also has a responsibility to the patient. It is in recognition of these factors that these rights are affirmed. 1. The right of efficient and equal service, regardless of race, sex, religion, ethnic background, education, social class, physical or mental handicap, or economic status. 2. The right of considerate, courteous and respectful care from all staff of the facility. 3. The right of complete information in terms that the average patient can reasonably be expected to understand. 4. The right to informed consent and full discussion of risks and benefits prior to any invasive procedure, except in an emergency. Alternatives to the proposed procedure must be discussed with the patient. 5. The right to know the names, titles, and professions of the facility staff to whom the patient speaks and from whom services or information are received. 6. The right to refuse examination, discussion and procedures to the extent permitted by law and to be informed of the health and legal consequences of this refusal. 7. The right of access to patient s personal health records. 8. The right of respect for the patient s privacy. 9. The right of confidentiality of the patient s personal health record as provided by law. 10. The right to make a complaint and to have your complaints reviewed in a timely, confidential manner. 11. The right to examine and receive a full explanation of any charges made by the facility. 12. The patient has the right to know the facility rules and regulations and how they apply to his/her conduct as a patient. 13. The patient has the right to request information regarding the ownership of the facility. No catalog of rights can guarantee for the patient the kind of treatment he has a right to expect. This facility has many functions to perform, including the prevention and treatment of disease, the education of both health professionals and patients, and the conduct of clinical research. All these activities must be conducted with an overriding concern for the patient, and above the recognition of his dignity as a human being. Success in achieving this recognition assures success in the defense of the rights of the patient. PATIENT RESPONSIBILITY 1. You need to give complete, accurate information about your health, including present condition, past illnesses, hospitalizations, medications, natural products and vitamins and any other matters or changes that pertain to your health. 2, Tell your healthcare team if you do not understand what they are telling you, or if you need more information. 3. You and your healthcare team should agree on a treatment plan. If you are unable to follow the plan, tell your doctor or nurse. 4. If you are not able to keep an appointment, please call the office as soon as possible to change the appointment. 5. Treat other patients, visitors, and medical staff with courtesy, compassion, and respect. 6. We encourage you to leave your valuable at home. The doctor s office is not responsible for lost or stolen belongings. If you believe any of your rights have been violated or you have other concerns or complaints about your care facility, you may contact the following: Texas Department of State Health Service Health Facility Compliance Group Post Office Box Austin, Texas (888) Complaints may be registered with the department by phone or in writing. A complainant may provide his/her name, address, and phone number to the department. Anonymous complaints may be registered. All complaints are confidential

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