NORTHSIDE PARK GASTROENTEROLOGY & ENDOSCOPY CENTER, PLLC

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1 NORTHSIDE PARK GASTROENTEROLOGY & ENDOSCOPY CENTER, PLLC PATIENT REGISTRATION Today s Date: / / Birthdate: / / S.S. # / / Patient Name: Age: Sex: Last First MI Address: City: State: Zip Code: Home Phone: ( ) Business Phone: ( ) Cell Phone: ( ) Occupation: Employer: Marital Status: Primary Insurance: Policyholder Name: _ Relationship: Secondary Insurance: Policyholder Name: Relationship: ID #: Group #: ID #: Group #: Primary Doctor: Pharmacy Name: Referring doctor: Pharmacy #: CONTACT/FAMILY PERSON NAME & TELEPHONE #: Effective January 1, 2010 all freestanding surgical facility providers are required to report to the Division of Public Health any selfreported race and ethnicity data provided by the patient. If you choose to self-report this information, please check the appropriate boxes: 1. RACE: (a) American Indian (b) Asian (c) African America (d) Caucasian (e) Other (f) Patient declined 2. ETHNICITY: (a) Hispanic (b) Non- Hispanic (c) Patient declined 3. NATIONALITY: (a) American (b) Canadian (c) Other 4. LANGUAGE: (a) English (b) Spanish (c) Other PRIVACY POLICIES NOTICE ACKNOWLEDGEMENT, IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPPA) AND ACKNOWLEDGEMENT OF RECEIPT OF A COPY OF OUR PATIENTS RIGHTS AND PATIENT RESPONSIBITIES POLICIES. I acknowledge that a copy of Northside Park Gastroenterology & Endoscopy Center s Privacy Policy Notice has been available to me in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I further acknowledge that I have received a copy of your Patient s Rights and Patient Responsibility Policies. I authorize the attending physicians to administer medical care as necessary. Northside Park Gastroenterology & Endoscopy Center will file all insurance claims as a courtesy to you. Given that we contact your insurance company; we are required to collect all co-pays, deductibles, and co-insurance due associated with your procedure. If you have any questions regarding your outstanding deductible and/or procedure co-pay and/or co-insurance, please consult your insurance company prior to procedure. I hereby authorize payment directly to Northside Park Gastroenterology & Endoscopy Center for all medical services provided to me, for benefits otherwise payable to me. This is to include major medical insurance and payment of medical benefits. I understand that I am financially responsible to the physician for charges not covered by assignment. I understand that should it become necessary to pursue collections through an outside agency for unpaid medical services, I will be responsible for all collection and attorney fees. All deductibles, co-insurance, and co-pays are due at the time of service. If you have no insurance, payment in full is expected at time of service. Patient Signature: Guardian Signature (if applicable): Date: Date:

2 NORTHSIDE PARK GASTROENTEROLOGY & ENDOSCOPY CENTER, PLLC PATIENT MEDICAL HISTORY FORM: ( Please if yes ) Name: DOB: Marital Status: Occupation: Age: Height: Weight: Referring doctor: (1). REASON FOR VISIT: Colon cancer screening History of colon cancer History of colon polyps Blood / Stool Heme Stool Anemia Rectal bleeding Constipation Diarrhea Abdominal pain Swallowing Problems Hepatitis Other (2). USE OF BLOOD THINNERS & NSAIDS: Coumadin Pradaxa Plavix Aspirin Ibuprofen Meloxicam Aleve Advil Naproxen BC powder Relafen Other (3). ALLERGIC TO: None Other: (4). PAST MEDICAL HISTORY: (5). PAST SURGICAL HISTORY: Do you require antibiotics prior to procedures? Have you ever had a blood transfusion? (6). SOCIAL & FAMILY HISTORY: (7). MEDICATION & DOSAGE Alcohol Use: Tobacco Use: Recreational Drugs: Family History of Colon Cancer: DOCTOR S NOTES: Patient Signature: _ Date:

3 REVIEW OF GENERAL HEALTH: (Please if yes ) Name: DOB: Date: GI Symptoms Cardiac/Respiratory Problems Ulcerative colitis Taking blood thinners Crohn s Disease Mitral valve prolapse Colon polyp Artificial heart valve Colon cancer History of Rheumatic Heart Disease Diverticulosis Take antibiotics for dental work Diverticulitis Sleep apnea Bloating/Gas Use CPAP Diarrhea Loud snoring Bloody diarrhea Swelling of legs Fecal incontinence Shortness of breath Constipation Chest pain Change in bowel habits Laxative use Blood Disorders Narrow stool caliber Excessive bleeding Abdominal Pain Excessive clotting Heartburn History of blood clots Acid regurgitation Anemia (low blood count) Nighttime regurgitation Cough or wheezing Endocrine Problems Difficulty swallowing Thyroid disease Painful swallowing Diabetes Lump in throat Excessive cold or heat intolerance Chest pain Nausea Neurologic or Psychiatric Disorders Vomiting Anxiety Blood in vomit Suicide attempt Blood in stool Depression Black stool Panic attack Anorexia Liver problems Bulimia Abnormal liver enzymes Drug addiction Hepatitis A Seizures Hepatitis B Stroke/TIA Hepatitis C IV drug use General Blood transfusion HIV infection Gallbladder disease Skin rash Light colored stool Fever Jaundice Itching Weight loss Joint pain Joint swelling Back pain Foreign travel Patient Signature Date Recent antibiotic use

4 NORTHSIDE PARK GASTROENTEROLOGY & ENDOSCOPY CENTER, PLLC Northside Park Gastroenterology & Endoscopy Center, PLLC wants you to be as comfortable as possible during your visit with us. We work extremely hard to meet all of your needs and answer all of your questions. If you have any concerns or questions please feel free to call PATIENTS RIGHTS Patients are treated with respect, consideration, and dignity. Patient rights will be exercised without regard to sex or cultural, economic, educational or religious background or the sources of payment for his/her care. Patients are provided privacy with respect to medical treatment and other decision making. Patient disclosures and records are treated confidentially, and except as required by law, patients are given the opportunity to approve or refuse their release. Patients are provided, to the degree known, complete information concerning their diagnosis, evaluation, treatment, and prognosis. When it is medically inadvisable to give such information to a patient, the information is provided to a person designated by the patient or to a legally authorized person. Patients have the right to receive as much information about any proposed treatment or procedure as he\she may need in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, alternate course(s) of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. Patients have the right to change physicians. Patients have the right to participate actively in decisions regarding his/her care medical care. To the extent permitted by law, this includes the right to refuse treatment. Patients have the right to confidential treatment of all communications and records pertaining to his/her care. Patients have the right to full consideration of privacy concerning his/her medical care. Case discussion, consultation, examination and treatment are confidential and shall be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual. Patients have the right to obtain reasonable responses to any reasonable Patients have the right to leave against the advice of his/her physician. Patients have the right to reasonable continuity of care, and to know in advance the time and location of his/her appointment, as well as the physician providing the care. Patients have the right to be informed by his/her physician, or a delegate of his/her physician, of continuing health care requirements. Patients have the right to examine and receive an explanation of his/her bill regardless of source of payment. Patients have the right to talk to the person who may have the legal responsibility to make decisions regarding medical care on behalf of the patient. Patients have the right to reasonable continuity of care, and to know in advance the time and location of his/her appointment, as well as the physician providing the care. Patients have the right to be advised if the facility or personal physician proposes to engage in or perform human experimentation affecting his/her treatment. The patient has the right to refuse to participate in such research projects without compromising access to care. Patients have the right to be made aware of services that are available at the organization. Patients have the right to receive information regarding fees and payment schedules. Patients have the right to have any complaints or suggestions. PATIENTS RESPONSIBILITY The patient has the responsibility to provide accurate and complete information concerning his/her present complaints, past medical history, and other matters relating his/her health. The patient is responsible for making it known whether he/she clearly comprehends the course of his/her medical treatment and what is expected of him/her. The patient is responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals, as they carry out the physician s orders. The patient is responsible for keeping appointments and for notifying the site or the physician when he/she is unable to do so. The patient should be knowledgeable of our efficiency in providing care in a timely manner without evidence of discrimination. The patient is responsible for his/her actions should he refuse treatment or not follow his/her physician s orders. The patient is responsible for assuring that the financial obligations of his/her care are fulfilled as promptly as possible. The patient is responsible for following facility policies and procedures. The patient is responsible for being considerate of the rights of other patients and facility personnel. The patient is responsible for being respectful of his/her personal property and that of other persons in the facility. The patient is expected to make a payment at the time of service unless other arrangements have been made in advance.

5 Health Insurance Durability and Accountability (HIPPA) Notice of Privacy Practices Northside Park Gastroenterology & Endoscopy Center, PLLC. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. You have the right to obtain a paper copy of this notice upon request. Patient Health Information Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information. How We Use Your Patient Health Information We use health information about you for treatment, to obtain payment, and for health care operations, including administrative purposes and evaluation of the quality of care that you receive. Under some circumstances, we may be required to use or disclose the information even without your permission. Examples of Treatment, Payment, and Health Care Operations Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescription, and to family members who are Helping with your care. Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payments from your health plan. Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, and to assess the care and outcomes of your case and others like it. Specials Uses We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. Other Uses and Disclosures We may use or disclose identifiable health information about you for other reasons, even without your consent, subject to certain requirements. We are permitted to give out health information without your permission for following purposes: Required by Law: We may require by law to report gunshot wounds, suspected abuse or neglect, or similar injuries and events. Research: We may use or disclose information for approved medical research. Public Health Activities: As required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities. Health oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities. Judicial and administrative proceedings: We may disclose information in response to an appropriate subpoena or court order. Law enforcement purposes: Subject to certain restrictions, we may disclose information required by law enforcement officials. Deaths: We may report information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies. Serious threat to health or safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Military and Special Government Functions: If you are a member of the armored forces, we may release information as required by military command authorities. We may also disclose information to correctional institutions or for national security purposes. Workers Compensation: We may release information about you for workers compensation or similar programs providing benefits for work related injuries or illness. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures. Individual Rights You have the following rights with regard to your health information. Please contact the person listed below to obtain the appropriate form for exercising these rights. Request Restrictions: You may request restrictions on certain uses and disclosures of your health information. We are not required to agree to such restrictions, but if we do agree, we must abide by those restrictions. Confidential Communications: You may ask us to communicate with you confidentially by, example, sending notices to a special address or not using postcards to remind you of appointments. Inspect and Obtain Copies: In most cases, you have the right to look at or get a copy of your health information. There may be a small charge for the copies. Amend Information: If you believe that information in your record is incorrect, or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Accounting of Disclosures: You may request a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or health care operations. Our Legal Duty We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the Notice currently in effect. Changes in Privacy Practices We may change our policies at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice in the waiting area and each examination room. You can also request a copy of our Notice at any time, for more information about our privacy practices, contact the person listed below. Complaints If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below. You may also send a written complaint to the U.S Department of Health and Human Services. You will not be penalized in any way for filing a complaint. Contact Person If you have any questions, request, or complaints, please contact: The Office Manager 102 Northside Park Drive Elizabeth City, NC Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C Effective Date: I, hereby acknowledge receipt of the Notice of Privacy Practices given to me. Signed: Date: If not signed, reason why acknowledgement was not obtained: Staff witness seeking acknowledgement Signed: Date: