Check-in is at The Oregon Clinic, West Hills Gastroenterology Endoscopy Center, located in Ste. 310.

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1 Welcome to The Oregon Clinic, West Hills Gastroenterology and our Easy Access Program! We are very glad you have chosen us to provide your gastrointestinal care. Please check the attached preparation instructions for your appointment date and time. We will be contacting you 5-7 days prior to your procedure to go over your preparation instructions in detail, and to answer any questions you may have. To facilitate our registration and check-in process, we ask that you fill out in advance the Medical History form, and bring this with you to your appointment. This doublesided form is located at the end of this packet. You may either bring your medication bottles with you to your appointment or a detailed list of your medications. Also, please bring your insurance card and photo identification. We strongly encourage you to contact your insurance company prior to your upcoming visit to verify your coverage and benefits for your scheduled appointment. Please be aware that the Easy Access Program may not be appropriate for everyone. If you have any of the following medical problems, please contact us immediately to discuss if Easy Access Colonoscopy is right for you. Blood in stool/hemoccult Positive stools Diarrhea Abdominal Pain Insulin Dependent Diabetes On Coumadin or Plavix Require the use of Oxygen Severe COPD Heart Failure or Renal Failure Severe Constipation Check-in is at The Oregon Clinic, West Hills Gastroenterology Endoscopy Center, located in Ste Should you need to cancel or reschedule your procedure, please provide 3 business days notice to avoid being charged cancellation/reschedule fees. Thank you again for choosing The Oregon Clinic, West Hills Gastroenterology. Should you have any questions regarding your upcoming colonoscopy, please call our patient Easy Access Phone Line Sincerely, The Staff from The Oregon Clinic, West Hills Gastroenterology RODGER A. SLEVEN, M.D. GEORGE KOVAL, M.D. CHRISTOPHER R. CARTER, M.D DIANE H. WILLIAMS, D.O. DOUG SHUMAKER, M.D. MICHAEL M. OWENS, M.D. ALAN H. KAYNARD, M.D., PH.D. JEFFREY WEPRIN, M.D. DAVID GRUNKEMEIER, M.D. CRISTIAN VALLEJOS, M.D. SARAH A. RODRIGUEZ, M.D. GLENN M. EISEN, M.D., M.P.H. SHANNON K. LEWIS, M.D S.W BARNES RD. SUITE 300 PORTLAND, OR (503) FAX (503) C

2 Billing Information You will receive multiple billings for services rendered in or through our facility. To assist you in expediting efficient processing of your claims, we ask that you provide the receptionist with accurate, current insurance information. This information will be forwarded to the organization associated with your care at this facility. If you require assistance, or have any questions regarding your billing, please use the table below to determine who is best able to answer your question. Thank you for allowing us to provide your GI care. BILL TYPE COVERS CONTACT INFORMATION Facility Fee Facility Usage The Oregon Clinic Equipment Phone: Nursing Care Hours/Days: 8:00 4:30 M-F Medical Supplies GI Physician Fee Procedure same as above Laboratory Fee Laboratory Services same as above Processing of Specimens Pathology Fee Pathology Cascade Pathology Professional Services Phone: Hours/Days: 9:00 5:00 M-F Anesthesia Fee Anesthesia Metropolitan Anesthesia Professional Services (Practice Management Group) Phone: Hours/Days: 8:30 7:30 (EST) M-F

3 THE OREGON CLINIC, WEST HILLS GASTROENTEROLOGY COLONOSCOPY CONSTIPATION PREPARATION INSTRUCTIONS (Gatorade/Miralax) The Endoscopy Center, 9701 SW Barnes Rd. Ste. 310 Procedure Date: Check-In Time: Physician: CALL US IF: You take coumadin, warfarin, Plavix or Pradaxa (you may need to be rescheduled if you are using these medications) You are insulin-dependent diabetic (you will need to be seen in our office prior to having your procedure) Purchase: TWO- 238gm bottles of Miralax over the counter at your pharmacy. TWO- 64 oz. bottles of Gatorade, Powerade or Propel that are LIGHT IN COLOR- Lemon-Lime is preferred. AVOID purchasing those that are red, purple, blue and green in color. Purchase (if you don t already have) 2 Dulcolax (bisacodyl) 5mg tablets over the counter at your pharmacy. They must be the laxative type, not the stool softener. Arrange for your ride home. You will not be permitted to drive yourself home from any sedated procedure. No public transportation (bus, MAX, Taxi Services) home unless accompanied by a responsible adult See attached sheet for Frequently Asked Questions and other important information. 7 Days Before Your Procedure: Stop all herbal medications, including, but not limited, to gingko, valerian root, garlic, ginger, etc. Stop taking iron and multivitamins with iron. 3 Days Before Your Procedure: Please stop eating celery, nuts, popcorn, seeds (poppy, sesame, berry, multi-grain breads/cereals, tomato, corn, etc). Please see the F.A.Q sheet attached if you accidentally consume some of the above. Discontinue fiber supplements, such as Metamucil, Citrucel, Benefiber etc. You may continue to eat fibercontaining foods. 2 Days Before Your Procedure: Between 4-6pm take the 2 Dulcolax (bisacodyl) tablets. The Day Before Your Procedure: From the time you awaken, begin a clear liquid diet. A list of acceptable beverages is on the back of this sheet. It is very important to increase fluid intake to prevent dehydration. Drink enough to keep urine clear, not yellow. At 4pm stop clear liquids. At 6pm, in a larger container, mix 1 bottle of Miralax in 1 bottle Gatorade (not red or purple in color). Mix the other bottle Miralax in the other bottle Gatorade. Shake or stir the solution until dissolved.

4 Using a STRAW drink 8 oz every minutes until first 64 oz bottle is finished and one- half of the second bottle is finished. You will begin to have diarrhea (this may take several hours to start) and your bowel movements should eventually become watery and clear. 1 Hour after finishing 1 and ½ bottles Miralax, you may resume your clear liquids. If you are diabetic there may be an adjustment to those medications. If you have questions, ask the physician managing your diabetes. The Day of Your Procedure: At: which is FIVE HOURS before your procedure begin to drink 8 oz of the remaining prep solution every minutes until solution is gone. You may have clear liquids until: which is TWO HOURS before your procedure time. THEN NOTHING ORALLY until after your procedure. If you normally take daily medications during this time, you may take them with a small sip of water unless otherwise instructed. Make sure your ride knows they must come to the endoscopy unit to pick you up; you will not be permitted to leave the department unaccompanied. If you are non-insulin dependent diabetic, DO NOT take your diabetic medication until procedure is finished. If you have questions, ask the physician managing your diabetes. You may not drive until the day after your procedure. If you must cancel or reschedule your procedure, notify us no later than 3 business days prior to your procedure in order to avoid a $ no-show fee (not covered by insurance). You will be ready to go home approximately 2-3 hours after check-in. ***Please have your ride arrive prior to 5pm as the office closes at this time.*** If you have any questions regarding this procedure or any of the above instructions, please contact our office at ext To reschedule (ext. ) Note to Driver It is not necessary for you to stay for the duration of the procedure. We can call you about 30 minutes ahead of the estimated discharge time. Our receptionist will ask the patient about this upon arrival for their procedure. Each patient has unique needs, and we strive to provide the highest quality of care to everyone we see. We try our best to accurately estimate the time your friend or family member will be ready after their procedure. We thank you for your patience and understanding.

5 Frequently Asked Questions for Colonoscopy What is a clear liquid diet? A clear liquid for this purpose is defined as any liquid you can read newsprint through that is not foggy or cloudy and is not dark in color. ACCEPTABLE LIQUIDS: Apple juice, white grape juice, white cranberry juice, strained lemonade or limeade, tea, BLACK coffee (no milk, cream or nondairy creamer), water, carbonated and non-carbonated soft drinks, Kool-Aid and Gatorade. Italian ices, ice-popsicles, Jell-O without whipped topping or fruit, hard candy. Clear broth or bouillon soups. RESTRICTIONS: Please avoid drinking anything that is dark in color. Do not have anything that is colored RED or PURPLE. Avoid drinking any milk, creamer and/or nondairy creamer. Do I have to use the straw? 1. No, it is not mandatory that you use the straw. However it can help prevent you from feeling nauseated while consuming your preparation. What if I feel nauseated or vomit while drinking my laxative preparation? 1. If you feel nauseated or if you vomit while taking the prep, stop drinking the laxative for minutes to let your stomach settle, then resume drinking as directed. 2. Try using the straw to drink your laxative; it helps bypass your taste buds and makes drinking easier. 3. Rinsing your mouth and gargling with mouthwash can eliminate any aftertaste between doses of preparation liquid. What if I accidentally consume nuts or seeds?: 1. Consuming a small amount of nuts or seeds will not prevent you from having your procedure. One or two dietary indiscretions will not ruin the preparation. You can still have your procedure. What do I do to prevent rectal irritation from the diarrhea? 1. You may use Vaseline or any water soluble lubricants for relief from any rectal irritation. DO NOT use Desitin ointment. 2. Consider trying flushable wipes to help avoid irritation from wiping with toilet paper. How fast will the laxative work? 1. The laxative will vary in how quickly it works from patient to patient. Some will experience diarrhea within an hour, others may have to wait several hours. What should I wear to my procedure? 1. Wear loose comfortable clothing that is easy to get in and out of. No nylons or pantyhose. 2. PLEASE leave all valuables at home, EXCEPT your insurance card and photo ID. Is there anything special I need to bring to my procedure? 1. If you use reading glasses, please bring them with you as you will need to read and sign a consent form and discharge sheet. 2. If you have an Advanced Directive, please bring it with you to your next appointment so we can file a copy in your chart. 3. Be prepared to describe your last few bowel movements. You will be asked about the color and appearance to make sure the preparation has worked. 4. Be sure you have arranged for your ride home. You will not be permitted to drive yourself.

6 IMPORTANT INFORMATION ABOUT YOUR COLONOSCOPY Please take a few minutes to read the following information, which will answer some frequently asked questions and help to prepare you for your upcoming procedure. A colonoscopy is a direct visual inspection of the entire length of your large intestine (colon). Colon cancer is a significant health problem in the United States, and it is the leading cause of cancer in non-smokers. Most people agree that colon cancer usually starts as a small, benign growth called a polyp which can turn into cancer slowly over time. Colonoscopies are performed on healthy individuals to find and remove these polyps, since removing them can greatly reduce your risk of developing colon cancer. There are other forms of colon cancer screening available; however, colonoscopy is considered the gold standard. Screening usually begins at age 50, although it may begin sooner if you have certain risk factors. The exam is performed after cleansing the colon and is done while you are sedated to ensure your comfort. Since colonoscopy is a visual inspection, the accuracy is directly related to the quality of the bowel cleansing. We advise you to read and follow the enclosed preparation instructions carefully. When you arrive at our office, you will be brought back into the recovery area where our staff will review your medical history and start an intravenous line. Once everything is ready, you will be brought into the procedure room and meet with your physician to discuss your exam further, to review the risks and benefits, and to answer any remaining questions. As with most medical procedures, there are infrequent risks associated with colonoscopy. These include, but are not limited to, risks of bleeding, perforation and sedation problems. In the case of colonoscopy, the benefits far outweigh the risks, which is why it is recommended that everyone undergo colorectal cancer screening. You will be asked to sign a consent form stating that you understand these risks, and that you choose to proceed with the colonoscopy. A copy of this consent form is included in your packet for your review prior to your arrival. Our goal is to make sure you are as relaxed, comfortable and prepared for your procedure as possible, and for you to have a complete and thorough evaluation of your colon. If you have additional questions about your colonoscopy, its risks, benefits, or alternative methods of colon cancer screening, please contact our office: Thank You, The Physicians and Staff of The Oregon Clinic, West Hills Gastroenterology

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8 Informed Consent for Anesthesia To the patient: This form is designed to confirm the discussion of and consent for proposed anesthesia to be administered for a therapeutic procedure. An anesthesia professional will administer anesthesia appropriate to my condition and will monitor vital bodily functions during the procedure(s). I understand that anesthesia involves risks in addition to the procedure itself. These risks may include, but are not limited to, possible adverse drug reaction, minor pain and discomfort, respiratory problems, low blood pressure and/or heart rate, unconscious state, injury to blood vessels and surrounding tissue, headache, heart attack/stroke, aspiration and dental injury. I am aware that in the administration of anesthesia other unexpected complications may occur. All of the above has been explained in terms I understand and my questions have been answered. I certify that information given by me as a patient regarding my history, problems, medications, food and fluid intake is correct. I understand that a responsible adult must accompany every patient home when discharged from the Recovery Room. I understand that disregarding such advice could place one at risk if problems develop and go unreported. I acknowledge I have read this form or had it read to me, and that I understand the risks, alternatives and expected results of the anesthesia service. I had ample time to ask questions. Date Time Signature Signature of Witness

9 THE OREGON CLINIC PATIENTS RIGHTS AND RESPONSIBILITIES OUR RESPONSIBILITIES As a patient of The Oregon Clinic you can expect: Considerate, respectful and compassionate care in a safe and secure environment. The right to personal privacy. The right to receive care free of all forms of abuse or harassment. The ability to exercise your rights without being subjected to discrimination or reprisal. The right to voice grievances regarding treatment or care that fails to be furnished. Information about your diagnosis, treatment, and expected result be provided by your specialist or designated staff in terms that you can understand before it has been performed. To receive the necessary information about a procedure or proposed treatment in order to give informed consent or to refuse this course of treatment. Assistance from a patient representative in expressing grievances or complaints verbally or in writing. Visit or MEDICARE, intake.pdf or Department of Human Services,Health Services,PO Box 14450,Portland, Or , To know who it is that is interviewing and examining you. Within the confines of the law, you can review your medical records and all communications and records pertaining to your care will be treated as confidential. All patients have the right to examine and receive an explanation of their bill, regardless of the source of payment. All patients or any legal representative of the patient, have the right to exercise the patient s rights to the extent allowed by State law. Have in effect and documented on your medical record any Advanced Directives concerning Living wills or medical powers of attorney. For further information visit YOUR RESPONSIBILITIES As a patient of The Oregon Clinic, you and/or your representative are expected to: Provide complete and accurate information about your health including present condition, past illnesses, hospitalizations, medications and any other information that pertains to your health. Provide complete and accurate billing information for claim processing and to pay bills in a timely manner. Ask questions when you do not understand what your doctor or a member of your health care team tell you about your diagnosis or treatment. You should inform your doctor if you anticipate not following prescribed treatment or are considering alternative therapies. Keep appointments, be on time for your appointments and notify your physician as soon as possible if you cannot keep your appointments. Be respectful of others and their property while in The Oregon Clinic facilities. PHYSICIAN DISCLOSURE As required by Federal Medicare regulations we are required to disclose that our physicians have a financial interest in The Oregon Clinic West Hills Gastroenterology Endoscopy Center.

10 Advance Directive Information Sheet The advance directive is a simple way to put your wishes about health care decisions in writing. It is a document in which you give instructions about your health care and what you want done or not done if you cannot speak for yourself. This document helps guide families and medical personnel in deciding the course of medical treatment to delay death. It usually spells out how aggressive medical treatment should be administered. In Oregon, the Health Care Decision Act (ORS ) allows an individual to name a person to direct your health care when you cannot do so. This person is called your health care representative. Your representative must agree to serve in this role and must sign the necessary forms. The following are included within the advance directive: o living will o medical power of attorney o pre-hospital medical care directive For further information on Advance Directives: Oregon Health Decisions at Advance Directive forms are available upon request or can be downloaded from: Completing an advance directive is completely voluntary. If you do not want an advance directive you do not need to complete the forms. TOC WHGI Endoscopy Center Advanced Directive Policy Life-sustaining efforts will be initiated and maintained on all patients who may have a cardiac/respiratory event while at TOC WHGI Endoscopy Center. If available, copies of any advanced directives will accompany the patient being transferred to another facility.

11 Payment Policy Patient Responsibility Patients are responsible for all charges resulting from treatment provided by The Oregon Clinic, West Hills Gastroenterology. Payment is due in full within 30 days of receiving your first statement unless other financial arrangements have been made with the Business Office. Co-pays All co-pays, if required by your plan, are due at the time of service for each visit. Payment Arrangements All patients will be required to pay off their balances within 30 days of receiving their first billing unless payment arrangements have been made with the billing office. Please contact our billing office as soon as possible after receiving your statement if payment arrangements are needed, (503) Uninsured Patient Deposits Patients without insurance will be required to make a deposit at the time of the visit for all appointments, as follows: New Patient Office Visits- $75 Return Patient Office Visits- $25 Procedures- $250 Referrals & Preauthorizations The Business Office will attempt to acquire a referral from your primary care doctor if your health plan requires one. Referrals can be difficult to obtain. Please be aware that if you choose to be seen before you have received a valid authorization prior to your appointment your insurance may not pay for the visit. If you are having a procedure that requires prior authorization, the Business Office will obtain this for you. The Business Office cannot guarantee payment for services or quote benefits from your health plan. Patients are ultimately responsible for knowing their coverage limitations and benefits. Insurance Billing As a courtesy we will bill your primary and secondary insurance for you. However, primary responsibility for the account is yours. Providing correct insurance billing information is the responsibility of the patient. If your insurance changes, please present your new card at your visit. All of our providers are participating providers with Medicare. If you are insured directly through the State of Oregon or are insured through Oregon Health Plan please bring your current medical card with you to each appointment. If you do not have your insurance card with you at the time of your visit you will be billed for the services if you have not provided us with valid insurance information. Cancellation/Rescheduling Fees If you need to cancel or reschedule your procedure, you must notify us within 3 business days of your procedure time. You may be charged a $100 cancellation/reschedule fee for insufficient notice for procedures. If you need to cancel or reschedule your office visit, you must notify us within 1 business day of your office visit time. You may be charged a $50 cancellation/reschedule fee for insufficient notice for office visits. No Show Fees You may be charged $100 for not showing for your scheduled procedure. You may be charged $50 for not showing for your scheduled office visit. Interpreter Fees If we have arranged for an interpreter for your visit or procedure, the interpreter service requires 24 hour notice of cancellation. If you do not show or late cancel, you may be billed for the interpreter fee in addition to the above. Collections We reserve the right to send accounts with balances that have been outstanding over 60 days from the date of service or the date of payment received from your insurance provider, whichever is more, to a collection agency S.W BARNES RD. SUITE 300 PORTLAND, OR (503) FAX (503)

12 Directions to: The Oregon Clinic, West Hills Gastroenterology WEST HILLS GASTROENTEROLOGY 9701 SW BARNES ROAD, SUITE 300 PORTLAND, OREGON FAX The Oregon Clinic, West Hills Gastroenterology Peterkort Centre 9701 SW Barnes Road, Suite 300 Portland, Oregon From Downtown Portland on Burnside Road West: Continue straight through the Miller Road intersection on Barnes Road. St. Vincent Hospital will be approximately two miles down on the right side of Barnes Road. Just past the hospital take an immediate right onto Baltic Avenue. Veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Downtown Portland on Highway 26 West: Continue on Highway 26 for six miles to the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From the Oregon Coast: Take Highway 26 East to the Park Way/Barnes Road exit, #69B. At the 1st light, follow the right fork (Blue signs will direct you to the Hospital). Continue straight through the next two signals (you will cross Barnes Road and you must be in the center lane to do so) and veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Washington: Take I-5 South across the Fremont Bridge. From there, take the Beaverton/Highway 26 West exit. Continue on Highway 26 for six miles and take the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Southern Oregon: Take I-5 North and exit onto Highway 217 North. Stay on Highway 217 for six miles (until it ends). Follow the Barnes Road East sign which will put you onto Barnes Road eastbound. Go to the first light and take a left onto Baltic Avenue. Veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. From Eastern Oregon: Take I-84 West to I-5 South and stay in the left lanes heading toward Beaverton. Cross the Marquam Bridge and take exit 1-D to Highway 26 West. Continue on Highway 26 for six miles and take the Park Way/Barnes Road exit, #69B. Take a right onto Baltic Avenue (you must be in the middle lane). Continue straight through the next signal (Barnes Road), veer left onto Lois Lane (at the fork in the road). We are the building on the right with the attached parking garage. toc NPP-MAP 4/09

13 WEST HILLS GASTROENTEROLOGY Procedure Medical History Form PLEASE PRINT USING BLACK INK Name Today s Date LAST FIRST MIDDLE Soc. Sec. # Date of Birth Age Sex Primary Care Doctor/Nurse: Referring Provider (if different from PCP): Have you ever been diagnosed with any of the following: q High Blood Pressure q Cancer q Gout q Heart Disease q Migraines q Glaucoma q Rheumatic Fever q Elevated cholesterol q Blood Transfusion q Stroke q Fibromyalgia q Seizure / Epilepsy q Asthma q Under / over - active thyroid q Sleep Apnea q Arthritis q Diabetes q COPD / Emphysema Have you ever had a Colonoscopy? q Yes q No If yes, where? when? Sedation History Have you previously undergone: IV Conscious Sedation (such as for a GI scope procedure )? q No q Yes Were there complications? (Please list) General Anesthesia? q No q Yes Were there complications? (Please list) Current Medications What Pharmacy do you currently use? Please bring a detailed list of medications with doses OR medication bottles OR fill out the table below. (Include over the counter medications and supplements). Medication Dose / Frequency Reason Do you take Coumadin (warfarin) or other blood thinners? q Yes q No Are you taking any supplements that contain Ginkgo Biloba? q Yes q No ALLERGIES to Medications Medication Reaction Do you have an ALLERGY to: Eggs? q Yes q No Soy? q Yes q No Lidocaine? q Yes q No Continued on next page toc PMHF 03/11

14 Name: Surgeries: Type of Surgery Date Doctor Where Have you ever been advised to have any surgical operation that has not been done? If yes, please explain: Family History: Does anyone in your family have a history of: Colon Polyps Colon Cancer Diagnosis Relation Age at diagnosis Habits: 1) Smoking / Tobacco / Nicotine use: Have you ever smoked or used tobacco / nicotine products? q Yes q No q Currently use: q Cigarettes per day q Chewing tobacco q Nicotine patch For how many years: q Used in the past: q Cigarettes per day q Chewing tobacco q Nicotine patch For how many years: How long ago did you quit? 2) Alcohol use: Do you drink alcohol? q Yes q No q Currently use: How much per week: q beer q wine q liquor q other Was alcohol ever a problem for you in the past? q Yes q No 3) Caffeine use: Do you drink caffeine-containing products? q Yes q No q Current use: How much per day: q coffee q tea q cola q other 4) Do you have a history of recreational or IV drug use? q Yes q No When? Ongoing? q Yes q No Patient Signature: Date: toc PMHF 03/11