Gastroenterology Specialties, P.C. & Lincoln Endoscopy Pre Procedure Form

Pre Procedure Patient Form

Patient's Personal Information
Name*
First Last
Middle Initial
Sex*
Race*
Ethnicity*
Language*
Address*
If apartment or suite, indicate in Address Line 2

Street Address Address Line 2 City State ZIP Code
Social Security Number #
Date of Birth*
Cell Phone*
Other Phone Numbers
Best time/days for Nurse to call:
Calls are made Monday-Friday 8:30AM-4:00PM
Employer / School Name
Date of your procedure*
MM slash DD slash YYYY
Email
Spouse's Name
Primary Insurance Company's Name
Primary Insurance Company's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Insured Information
Name of Insured Date of Birth Relationship to Insured Primary Insurance ID # Primary Group ID #
Secondary Insurance Company's Name
Secondary Insurance Company's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Insured Information
Name of Insured Date of Birth Relationship to Insured Secondary Insurance ID # Secondary Group ID #
Patient History
Please fill out this information to the best of your ability.
Primary Care Physician*
Chief Complaint*
Have you had any previous Colonoscopy or Endoscopy at any other facility?
Please include type, location of procedure, and year.
Test performed: Facility performed at or physician name: Approximate date:
Current Height*
Current Weight*
Pharmacy of Choice and Location:*
If you have a mail order pharmacy and a local pharmacy, please advice which is primary.
Do you take prescription medications?*
- Yes
- No
Prescription Medications*
Name Reason Dosage Frequency
Do you take over the counter medications/vitamins*
- Yes
- No
Over the counter Medications/Vitamins*
Name Reason Dosage Frequency
Medication Allergies*
- I do not have any medication allergies
- I am allergic to latex
- I have other allergies to list
Reaction to Latex
- Rash and/or itching
- Hives
- Difficulty breathing
- Anaphylaxis
- Other
Other Allergies
Leave blank if no other allergies
Medication allergic to Reaction type
Surgical History*
Please list any abdominal, heart or lung surgeries, joint replacements, or metal implant/insertions (ie: rods, plates, screws)
Surgery type Date
Please select all that apply*
- None apply
- Past Blood Transfusion?
- Complications with Sedation/Anesthesia?
- Malignant Hyperthermia or Family History of Malignant Hyperthermia?
Explain your complications with sedation/anesthesia.
Alcohol Use?*
- None
- Social use/Daily use
- Recovering Alcoholic
How many drinks per week or per day, please specify
Date you quit drinking
Tobacco Use*
- Never Smoker
- Former Smoker
- Current Smoker
Cigarettes per day
Year Quit
Recreational Drug Use*
- Never used
- Previous drug use
- Current drug use
List of drugs and year quit
List current recreational drugs use
Family History
Has anyone in your Immediate Family (ONLY Parents, siblings, children) had any of the following?
Celiac Disease*
- Yes
- No
List relationship to person who had Celiac Disease
Colon Cancer*
- Yes
- No
List relationship to person who had Colon Cancer and approximate age at diagnosis:
Colon Polyps*
- Yes
- No
List relationship to person who had Colon Polyps and approximate age at diagnosis:
Crohn's Disease*
- Yes
- No
List relationship to person who had Crohn's Disease:
Liver Disease*
- Yes
- No
List relationship to person who had Liver Disease:
Pancreatic Disease*
- Yes
- No
List relationship to person who had Pancreatic Disease:
Ulcerative Colitis*
- Yes
- No
List relationship to person who had Ulcerative Colitis:
Ulcers*
- Yes
- No
List relationship to person who had Ulcers:
Review of Systems - PLEASE CHECK ALL THAT APPLY TO YOU ONLY
Please check any that apply to you
Respiratory*
- Not Applicable
- Asthma
- Coughing up blood
- Chronic Cough
- Emphysema
- History of Pulmonary Embolism
- CPAP
- Oxygen Therapy
- Pneumonia
- Shortness of Breath
How many liters of Oxygen are you on, and when (ie: all day, only at night, only with activity)?
CPAP Type of Mask?
- Nasal Mask
- Full Mask
Cardiovascular*
- Not applicable
- Chest pain
- Defibrillator
- Heart Attack
- Heart Murmur
- Hypertension
- Irregular/rapid heartbeat
- Low blood pressure
- Pacemaker
- Stents in the last 6 months
- Swelling of legs, ankles, feet
- Valve replacement
- valvular disease
Approximate date of heart attack (list month/year if possible)
Approximate date of cardiac stent (list month/year if possible)
Gastrointestinal*
- Not applicable
- Abdominal pain - NEW
- Abdominal pain - chronic
- Change in appetite
- Change in bowel habits
- Constipation - NEW
- Constipation - chronic
- Crohn's disease
- Diarrhea - NEW
- Diarrhea - chronic
- Diverticulitis
- Diverticulosis
- Heartburn
- Hemorrhoids
- Hepatitis
- Indigestion
- Jaundice
- Nausea
- Pancreatitis
- Colon polyp or tumor
- Rectal bleeding
- Trouble swallowing
- Ulcer
- Ulcerative Colitis
- Vomiting
Neurological*
- Not applicable
- Stroke
- TIA
Approximate date of TIA or Stroke (list month/year if possible)
How frequently do you have bowel movements?
HIPPA FORM
Please Review the HIPAA Privacy Statement/Notice of Privacy Policies before continuing.
Notice of Privacy Policies Acknowledgement
- I have read the NOTICE OF PRIVACY POLICIES OF GASTROENTEROLOGY SPECIALTIES, PC AND LINCOLN ENDOSCOPY CENTER, LLC.
File Storage Notice
- I understand that a copy of this signed Acknowledgement of Receipt of Privacy Policies will be kept on file.
Availability of Copies
- I understand that if I desire a copy of the Notice or Privacy Policies, or my signed copy of the Acknowledgement of Receipt of the The Notice of Privacy Policies, I may be given such copy upon request.
Authorization to disclose personal health information to:*
Please list self only or names of family members/other persons.
We are here to assist you in providing information to your Health Insurance Company so that payment may be MADE ACCORDING TO THE COVERAGE YOU HAVE PURCHASED. PLEASE KEEP IN MIND THAT NOT ALL SERVICES ARE A COVERED benefit in all Plans and that your insurance coverage is an agreement between you and your insurance company. Payment for services at Gastroenterology Specialties, P.C. and/or the Lincoln Endoscopy Center, L.L.C. are ultimately the patient's responsibility.
Insurance Pre-Authorization is the PATIENT'S RESPONSIBILITY!
If your Insurance Plan requires an authorization for care or treatment, it is the PATIENT'S responsibility to obtain one prior to your visit. Contact your Insurance Carrier if you are not sure. IF a referral is not obtained, your insurance company may deny payment coverage and could result in patient responsibility.

Patient Deductibles, Coinsurance and Co-Pay Responsibility
Patient Deductibles, Coinsurance and Co-payment amounts are established by your Health Plan and are due at the time of service. This does include the Nebraska Department of Human Services Medicaid Program. You will be contacted prior to your appointment to review your insurance benefits and discuss a payment arrangements for your deductibles and coinsurance.

Insurance Filing
We will file your primary and secondary insurance for you as a courtesy if the following conditions are met:
1. The Assignment of Benefits (below) has been signed.
2. Primary and secondary insurance information is provided to us at the time of the visit.
PATIENTS WHO FAIL TO PROVIDE INSURANCE INFORMATION ARE DIRECTLY RESPONSIBLE FOR PAYMENT OF THEIR ACCOUNT.

Services provided by the physicians of Gastroenterology Specialties, P.C. will be billed separately from the facility charge at the Lincoln Endoscopy Center, L.L.C.

No Insurance Coverage - Payment is due at time of service, or acceptable payment plan reached before the date of service.

Checks, Cash, Visa, MasterCard, Discover and Debit Cards are accepted. Payment arrangements must be arranged prior to the visit. An Account Representative will be happy to assist you and can be reached at (402) 465-3636. They will be happy to assist you with any questions you may have regarding these available payment options.
Deliquent Accounts
- I understand accounts that have not been paid within 30 days of initial billing will be considered delinquent. These accounts may be charge interest. If acceptable payment arrangements have not been made, these accounts will be considered for collection or legal action. In the event of nonpayment, you are responsible to pay the cost of collection and/or court costs and reasonable fees should they be required.
ASSIGNMENT OF BENEFITS
- I hereby give authorization to release medical information necessary to process my health insurance claim and request payment of benefits be made to Gastroenterology Specialties, P.C. and/or the Lincoln Endoscopy Center, L.L.C. I understand I am financially responsible for charges not covered or denied by my insurance company. A photocopy of this agreement shall be as valid as the original. This authorization is to remain in effect until revoked in writing by me or my legal representation.
Financial Agreement
- I have read and agree to the terms and conditions of the Financial Policy of Gastroenterology Specialties, PC and Lincoln Endoscopy Center, LLC as stated above. I agree that a photocopy of this agreement shall be as valid as the original.
Patient Rights and Responsibilities
Please Review the Patient Rights and Responsibilities.
Patient's Signature or Responsible Party*
By typing your name, you agree to all agreements found in this form.
Today's Date*
Month
Day
Year
Once all sections have been filled out and submitted, instructions will be sent to you regarding the procedure and prep. Please call if you have questions.

Name of Insured	Date of Birth	Relationship to Insured	Primary Insurance ID #	Primary Group ID #

Name of Insured	Date of Birth	Relationship to Insured	Secondary Insurance ID #	Secondary Group ID #

Test performed:	Facility performed at or physician name:	Approximate date:

Name	Reason	Dosage	Frequency

Pre Procedure Patient Form

Patient's Personal Information

Patient History

Family History

Review of Systems - PLEASE CHECK ALL THAT APPLY TO YOU ONLY

HIPPA FORM

Patient Rights and Responsibilities

Once all sections have been filled out and submitted, instructions will be sent to you regarding the procedure and prep. Please call if you have questions.