- Financial Policy and Notice of Privacy Practices are for your records
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1 Paul S. Chard, M.D., Ph.D. E. Michael Darby, M.D. Susie Ng Cohn, M.D. Neil H. Stollman, M.D. Liana Vesga, M.D. Silvia M. Villagomez, M.D. Danny Wu, M.D. Lynne Tavera, NP-C Luba Teytelman, PA-C Welcome to East Bay Center for Digestive Health, EBCDH is the largest single specialty gastroenterology group practice in the East Bay and comprises seven Board certified gastroenterologists with first rate clinical training and a dedication to providing excellent diagnostic and clinical care. We also have a certified Nurse Practitioner and certified Physician Assistant who each have over 10+ years of experience in the field of Gastroenterology. We are committed to exceeding your health care expectations. You are receiving this letter because your primary care physician has referred you to our office and you are scheduled for an endoscopic procedure. Your colonoscopy and/or upper endoscopy will be performed at East Bay Endosurgery Center, a state of the art facility located in our building in Suite 135. Please see the instructions below for completing your REGISTRATION FORMS - Complete pages 2 through 6 and return to the office at least 2 weeks prior to your procedure WITH A COPY OF YOUR IINSURANCE CARD o It is important that we are able to review your medical history prior to your procedure AND be able to verify that we are contracted with your insurance and have the correct payer information on file - Financial Policy and Notice of Privacy Practices are for your records - Please read and sign pages 7 and 8 You can return these with the rest of the forms or bring them with you to your appointment. If you have not completed and returned forms prior to your procedure, you will be asked to complete them at the time of your visit. Depending on your medical status, your procedure may need to be rescheduled or even cancelled. If you are driving, please allow time to find parking. If you have any additional questions, do not hesitate to call your Procedure Coordinator at the extensiojn provided on your procedure instructions. 300 Frank Ogawa Plaza, Suite 450 Oakland, CA Tel: (510) Fax: (510)
2 Patient Name: Sex: M/F Date of Birth: Address: City/State/Zip: Mobile Phone: Home Phone: Other Phone: SSN#: Language: Race/Ethnicity: Primary Insurance: ID# - Are you the subscriber for this insurance plan? Y/N If no, who is? (name/dob) Secondary Insurance: ID# - Are you the subscriber for this insurance plan? Y/N If no, who is? (name/dob) Emergency Contact (Name & Phone #): CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS I understand that as a part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. EBCDH, Inc. will use and disclose my protected health information ( Health Information ) as defined by federal and state law, in the manner described below: A basis for planning my care and treatment. A means of communication among the many healthcare professionals who contribute to my care. A source of information for applying my diagnoses and surgical information to my bill. A means by which a third party payer can verify that services billed were actually provided. A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals. I understand that I have the right: To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. Any and all of the following Health Information may be disclosed by EBCDH, Inc. on my behalf below for the follow reasons: Medical Information can be discussed with Patient only Family/Friend Name Spouse/Significant Other Name Other Representative Billing Information and attempt to collect payment can be discussed with Patient only Family/Friend Name Spouse/Significant Other Name Other Representative Detailed message regarding test results can be left on answering machine YES At this phone number only NO It is okay to communicate via via my Patient Portal YES NO Address: Signature of Patient or Legal Rep. Date Witness Signature PATIENT NAME: DATE OF BIRTH: 2
3 REFERRING MD: PHARMACY/PHONE#: MAIN REASON FOR CONSULTATION TODAY (CHIEF COMPLAINT): Required: HEIGHT: WEIGHT: CURRENT OR CHRONIC/ONGOING GI CONDITIONS. Please list DATES. Stomach ulcers Colon polyps Diverticulosis Gallstones Colitis Crohn s Irritable Bowel Syndrome Colon Cancer Hepatitis (inflammation of the liver, sometimes from a virus) Type: A B C History of GI infection(s) (which) PREVIOUS GI PROCEDURES OR IMAGING Endoscopy of the stomach Colonoscopy Sigmoidoscopy in the past 5 years Liver Biopsy Abdominal ultrasound MOST RECENT DATES GI SURGERY: Gallbladder surgery Appendectomy Other ALL OTHER SURGERIES: CURRENT OR CHRONIC/ONGOING MEDICAL CONDITIONS Heart Disease Angina MI (date) Cardiac stent/valve replacement Pacemaker Defibrillator Arrhythmia Valvular disease Stroke (date) Seizures DVT/PE (date) Sleep apnea Obesity lbs Diabetes High cholesterol High blood pressure Arthritis Gout Kidney disease Kidney dialysis Blood transfusions HIV Cancer (type) Immunologic disorder COPD Asthma Tuberculosis Bleed/clot disorder Psychiatric Other medical conditions DRUG ALLERGIES (medicines, iodine, or radiology contrast) List with reactions FAMILY HISTORY Check if your parents, grandparents, brothers, sisters or children have or had any of the following: Problems like you are having Liver disease Hereditary diseases (list) Colon cancer (list relationship, maternal/paternal, and age at diagnosis if known) Colon polyps Other cancers (list relationship, maternal/paternal, and age at diagnosis if known) SOCIAL HISTORY Currently disabled Any Mobility Impairments? (i.e. wheelchair) Current smoker, how many per day? Former smoker, year quit? Never smoked Current drinker (alcohol), how much? per week Don t drink alcohol Intravenous drugs not prescribed by a physician or other street drugs No IV or street drugs Born outside the US?, which country REVIEW OF SYSTEMS 3
4 In the last 6 months have you experienced any of the following? Do you currently have? Date of last Occurrence? GENERAL Yes No Fever/chills? Unintentional weight loss? Amount: Lbs since when? Fatigue / tire easily? EYES/MOUTH/THROAT Yes No Eye inflammation / redness? Non-healing mouth sores? Sour taste in your mouth? Stomach contents in your mouth? Sore throat? Hoarse Voice? Severe tooth decay? CARDIAC Yes No Chest pain or pressure? Palpitations (sensation of heart beating in chest)? RESPIRATORY Yes No Shortness of breath? Wheezing / asthma? GASTROINTESTINAL Yes No Heart burn / acid reflux? Difficult / painful swallowing? Nausea / vomiting? Poor appetite? Diarrhea (loose or frequent stools)? Constipation? Bloody or black bowel movements (on Iron? Pepto Bismol?) Vomiting blood? Significant abdominal pain or cramping? MUSCULOSKELETAL Yes No Joint pain? Back pain? SKIN Yes No Rash? Jaundice (yellowing of the skin or eyes)? Easy bruising or bleeding? NEUROLOGICAL Yes No Trouble thinking clearly? Fainting? PSYCHOLOGICAL Yes No Stress at work or home? Feeling anxious or depressed? BLOOD/LYMPH Yes No History of anemia? Bleeding or clotting disorder? Initials Date 4
5 PATIENT MEDICATION LIST So that we may maintain the highest quality in care and safety, please fill in ALL MEDICATIONS that you take Please be sure to include all asthma, heart and blood pressure medications, any narcotics you may take (Percocet, etc.), and any over the counter or herbal medications, medical creams or sprays and any supplements PLEASE PRINT LEGIBLY MEDICATION NAME DOSE (ml/mg) TIMES PER DAY WHAT ARE YOU TAKING THIS MEDICATION FOR? NOTES THE ABOVE NOTED LIST IS TRUE, CORRECT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF: Print Name Patient Signature Date I do not take any medications at this time. Print Name Patient Signature Date 5
6 East Bay Center for Digestive Health Medical Associates, Inc. Paul S. Chard, M.D., Ph.D., E. Michael Darby, M.D., Thomas B. Hargrave, III, M.D. Susie Ng Cohn, M.D., Neil H. Stollman, M.D., Liana Vesga, M.D., Silvia M. Villagomez, M.D., Danny Wu, M.D. Direct Referral Screening Colonoscopy General Information and Colonoscopy Consent Form Background: In the United States, colorectal cancer (CRC) is the second leading of cancer deaths (lung cancer is the leading cancer). Approximately 150,000 new cases are diagnosed in the US every year. Screening has been shown to decrease death from CRC. Your primary care physician has referred you to have a screening colonoscopy. What is it? Colonoscopy is a procedure that allows your physician to see the inside of your colon and rectum using a flexible tube (about the width of your index finger) containing a light and camera. This technology gives the physician the ability to take biopsies and remove suspicious findings if any are seen. What to expect: On the day before the procedure you will not be allowed to eat ANY solid foods. However, you will be allowed to have clear liquids. Sometime during the DAY BEFORE the procedure you will begin a bowel preparation to clean out your colon. Please read the bowel preparation instructions for specific further details these are sent to you once the procedure is scheduled. Because this test can be mildly uncomfortable, you will be receiving some type of anesthesia to make you sleepy during the exam, but you will not lose consciousness and will be breathing on your own. Most patients do not recall having the procedures done because the sedatives can impair short-term memory. The procedure typically takes less than 30 minutes. Recovery time is typically less than 60 minutes. Due to the anesthesia you will be receiving, you will not be allowed to drive home from the procedure. You will need a responsible adult to take you home. You cannot take a taxi or other service, i.e. Uber. You can have a light meal after your procedure and the remainder of the day should be spent resting. Due to the anesthesia, your judgment might be impaired for the remainder of the day, so you shouldn t make any big decisions or operate machinery. The next day you should be back to normal. RISKS, BENEFITS, AND ALTERNATIVES: The risk of serious consequence from screening colonoscopy is very low. Potential serious complications include bowel perforation (approximately 1 in 1,000), there is a small risk of heavy bleeding after removal of polyps (approximately 1 in 1,000) and death (approximately 1 in 20,000). Other possible risks include adverse reaction to sedation, and missed lesions. Alternatives to a screening colonoscopy include a radiology test called barium enema, a flexible sigmoidoscopy, yearly stool test cards, which check for blood, and choosing not to have investigation performed. If you have more specific questions regarding the procedure itself or the risks, benefits and alternatives, you are advised to make an office visit to fully answer all your questions before scheduling the procedure. I acknowledge that I have been informed about screening colonoscopy and the risks, benefits and alternatives. Additionally, I understand I need to cancel my procedure at least 72 business hours in advance to avoid a cancellation fee. Print Name Patient Signature Date 6
7 ACKNOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICY I, have received a copy of the Financial Policy for Practices for East Bay Center for Digestive Health. Please print name SIGNATURE Date ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, have received a copy of the Notice of Privacy Practices for East Bay Center for Digestive Health. Please print name SIGNATURE Date FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (please specify) 7
8 NOTIFICATION Please be informed that the physician who is rendering services to you has ownership interest in this facility. East Bay Endosurgery was designed and built specifically to provide outpatient GI endoscopy procedures and to meet the needs of our community. Our staff consists of licensed nurses and certified technicians who are specifically qualified to assist in endoscopic procedures. The combination of our physicians and this group of dedicated professionals ensures the highest quality healthcare for our patients. By signing this document you indicate that you are aware of their ownership interest and understand that you can request that your procedure be scheduled at Summit Hospital, but have decided to have your procedure performed at East Bay Endosurgery. Though the physician may be contracted with your specific health plan, in some cases the facility may not. The insurances listed below are contracted with the facility; Aetna, Alameda Alliance, CHCN (except Blue Cross), Blue Cross, Blue Shield, Cigna, First Health, Health Net, Medicare, Medicare/Medi-Cal (as a secondary) Pacific Care, United Health Care, PHCS, Great West, Interplan, Beech Street, Tricare, Three Rivers Provider Network and PHCS. If your particular insurance is not listed, then it is not contracted with the facility. Many insurance plans offer out-of-network benefits which allow you to use a nonparticipating facility, while others do not. In either case, East Bay Endosurgery will strive to keep your out-of-network expenses competitive with the rates charged by in-network hospital facilities. Please be aware that deductibles and co-insurances are due at the time services are rendered to you. As is customary, insurance plans make a distinction between the fee the physician charges and the fee the facility charges. Per standard billing practices, your insurance will be billed two separate claims for these services. When East Bay Endosurgery submits a claim to a non-contracted insurance, it is possible they will forward the payment directly to you because it is not in-network. We are asking for your cooperation in making this process run smoothly. When you receive the payment for the services provided, please sign and forward the payment to our office. Please remember that you are ultimately responsible for all charges. Should you have any questions regarding your bill, please contact our billing office at (510) , Option 1 for billing questions regarding the doctor s fee, Option 2 for billing questions regarding the facility fee. I have read and understood the above statement. Signed: Date: 8
9 9
COLON & RECTAL SURGERY, INC.
COLON & RECTAL SURGERY, INC. Please complete attached paperwork and bring to your appointment with your insurance card, co-pay and photo ID. If a referral is required, please be sure to contact your insurance
Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
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