PIF – Gastroenterology Clinic

First Name(Required)

Middle Initial

Last Name(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Social Security #

Date of Birth

Sex

Male

Female

Other

Marital Status

Home Phone or Mobile Phone (Best)(Required)

Work Phone

Email(Required)

Contact Preference

No preference

Email

Letter/phone

Decline to specify

Other

Patient Employer

Insurance Name

Policy ID #

Policy Holder's Name

Policy Holder's D.O.B.

Spouse's Information

Spouse’s Name:

Spouse’s Date of Birth

Spouse’s SSN

Spouse’s Employer

Spouse’s Work #

Spouse’s Mobile #

Emergency Contact

Emergency Contact (other than spouse)

Relationship to Emergency Contact

Emergency Contact Phone #

Emergency Contact Mobile #

Person(s), if any, we may discuss your medical/billing information with

Name

Relationship

Name

Relationship

Provider you are seeing today

Referring Provider

Reason for visit today

Race

Black/African American

White

Asian

American Indian/Alaska Native

Decline to specify

Ethnicity

Hispanic

Not Hispanic or Latino

Decline to specify

Preferred Language

English

Spanish/Castilian

Decline to specify

*Please answer the following questions as accurately as possible. Your past medical history and your family history are used to determine what your insurance will cover for procedures. Inaccurate information can affect how your claim is paid. Please initial in the box after answering the questions.

Have you ever had a colonoscopy?

Yes

No

When did you have a colonoscopy?

Where did you have a colonscopy?

Have you ever had colon polyps?

Yes

No

Have you ever had colon cancer?

Yes

No

Has anyone in your immediate family ever had colon polyps?

Yes

No

Which family member had colon polyps?

Mother

Father

Sister

Brother

Daughter

Son

Has anyone in your immediate family ever had colon cancer?

Yes

No

Which family member had colon cancer?

Mother

Father

Sister

Brother

Daughter

Son

*All question in this box have been answered to to best of my knowledge.

Authorization to Pay Benefits

I hereby authorize payment of surgical and/or medical benefits directly to Gastroenterology Clinic, APMC (herein after GC), Endoscopy Center of Monroe, Inc. (herein after ECM) and/or West Monroe Endoscopy ASC, LLC (herein after WME) and further convey, transfer, and assign all of my rights in my insurance coverage to GC, ECM and/or WME for services rendered. I also hereby assign and transfer any and all rights, title, and interest to any claim for penalties and/or attorney fees arising under any state or federal law or regulation related to the payment of any claim for benefits to GC, ECM and/or WME. Regardless of the extent of the insurance coverage, I agree to be responsible for the entire balance. I also authorize release of information pertaining to my claim to my insurance company and/or companies or my attorney. Once the provider has obtained the patient's one-time authorization, the provider may submit any later claim on either an assigned or unassigned basis without obtaining any additional signature from the patient. In submitting claims, the provider should indicate "Patient request for payment on file." I hereby authorize GC, ECM, WME to furnish information to any requesting physician.

Medicare Authorization

I certify that the information given to me in applying for a payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediary of carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf once the provider has obtained the patient's one time authorization. The provider may submit any later Medicare claim on either an assigned or unassigned basis without obtaining any additional signature from the patient. In submitting claims, the provider should indicate "Patient request for payment on file." I hereby authorize Gastroenterology Clinic, APMC, Endoscopy Center of Monroe, Inc. and/or West Monroe Endoscopy ASC, LLC to furnish information to any requesting physician.

Patient Interview Form

Spouse's Information

Emergency Contact

Person(s), if any, we may discuss your medical/billing information with

Review of Systems/Current Symptoms: Please check yes or no

Consent to Import Medication History

Past or Present Medical Conditions

Diagnostic Tests

Social History

Family Medical History: (This section pertains to your family, not your personal medical history)

Consent to Share Data

Reminder Preference

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