Gastroenterology Specialties, P.C. & Lincoln Endoscopy NDOC patient registration

1 NDOC Patient Registration Form

Patient's Personal Information
Name*
First Last
Middle Initial
Marital Status*
Sex*
Race*
Ethnicity*
Language*
Appointment Date
MM slash DD slash YYYY
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*
Home / Main Phone
Work Phone
Cell Phone
Employer / School Name
Email
Spouse's Name (Enter NONE if Not Married)
Spouse's Employer
Spouse's Work Phone
Patient's Insurance Information
Primary Insurance Company's Name
Primary Insurance Company's Address
Street Address Address Line 2 City State ZIP Code
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 ZIP Code
Secondary Insured Information
Name of Insured Date of Birth Relationship to Insured
Secondary Insurance ID # Secondary Group ID #
Patient / Responsible Party Information
If the insurance is under the patients name this section can be left blank. Please move on to "Patient referral Information"
Responsible Party (Name)
Date of Birth
Relationship to Patient
Social Security Number #
Home Phone
Work Phone
Address
If apartment or suite, indicate in Address Line 2

Street Address Address Line 2 City State ZIP Code
Employer's Name
Patient's Referal Information
Referred by Physician*
Other Physician(s) Who Care for You
Emergency Contact Information
Name (of Person Not Living with You)
Relationship
Emergency Home Phone
Emergency Work Phone
Patient History
Please fill out this section if you have not been seen in the last year.
Chief Complaint*
Describe the symptoms and issues you are having
Have you had testing for this complaint?
Please include any previous Endoscopy, X-rays, Lab procedures, etc. Write NONE if no testing has occurred.
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.
Prescription Medications (CLICK THE + TO ADD MORE MEDICATIONS)*
Name Reason Dosage Frequency
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*
- Select All
- Rash and/or Itching
- Hives
- Difficulty breathing
- Anaphylaxis
- Other
Other Allergies
Leave blank if no other allergies
Medication allergic to Reaction type
Surgical History*
Surgery type Date
Please select if Yes
Please select if Yes
- Past Blood Transfusion?
- 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
Caffeine Use
- Coffee
- Tea
- Soda
- Energy Drinks
- None
Caffeine Use
Caffeine type Daily Amount
Family History
Has anyone in your Immediate Family (Parents, siblings, children) had any of the following?
Celiac Disease*
- Yes
- No
- Unknown
List relationship to person who had Celiac Disease
Colon Cancer*
- Yes
- No
- Unknown
List relationship to person who had Colon Cancer and approximate age at diagnosis:
Colon Polyps*
- Yes
- No
- Unknown
List relationship to person who had Colon Polyps and approximate age at diagnosis:
Crohn's Disease*
- Yes
- No
- Unknown
List relationship to person who had Crohn's Disease:
Liver Disease*
- Yes
- No
- Unknown
List relationship to person who had Liver Disease:
Pancreatic Disease*
- Yes
- No
- Unknown
List relationship to person who had Pancreatic Disease:
Ulcerative Colitis*
- Yes
- No
- Unknown
List relationship to person who had Ulcerative Colitis:
Ulcers*
- Yes
- No
- Unknown
List relationship to person who had Ulcers:
Review of Systems
Please check any that apply to you
Constitutional
- Chills
- Fever
- Recent Weight Gain
- Recent Weight Loss
ENT
- Dentures
- Hearing Loss
- Sinus problems
- Sores in mouth
Respiratory
- Asthma
- Coughing up blood
- Chronic Cough
- Emphysema
- History of Pulmonary Embolism
- Oxygen Therapy
- Pneumonia
- Shortness of Breath
Cardiovascular
- Chest pain
- Defibrillator
- Heart Attack
- Heart Murmur
- Hypertension
- Irregular/rapid heartbeat
- Low blood pressure
- Pacemaker
- Stents in the last 30 days
- Swelling of legs, ankles, feet
- Valve replacement
- valvular disease
Gastrointestinal
- Abdominal pain - NEW (<3 months)
- Abdominal pain - CHRONIC (3 or more months)
- Change in appetite
- Change in bowel habits
- Constipation
- Crohn's disease
- Diarrhea - NEW (<3 months)
- Diarrhea - CHRONIC (3 or more months)
- Diverticulitis (infection of diverticulosis pockets)
- Diverticulosis (pockets in colon lining)
- Heartburn
- Hemorrhoids
- Hepatitis
- Indigestion
- Jaundice
- Nausea
- Pancreatitis
- Colon polyp or tumor
- Rectal bleeding
- Trouble swallowing
- Ulcer
- Ulcerative Colitis
- Vomiting
CONSTIPATION INFO*
- NEW (<3 months)
- CHRONIC (3 or more months)
- BM every day
- BM every 2 days or less
- Hard stools
- Incomplete evacuation
Genitourinary
- Dialysis
- Kidney Stones
- Kidney Disease
- Renal Failure
Musculoskeletal
- Arthritis
- Artificial Joints
Hematologic/Lymphatic
- Anemia
- Anticoagulation Therapy
- Blood Clots
- Blood Disorder
- Phlebitis
- Transfusion
Endocrine
- Cortisone Therapy
- Diabetes
- Thyroid Problem
Immunologic
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Tuberculosis
- C-Diff
- VRE
- MRSA
Neurological
- Headaches
- Paralysis
- Stroke
Psychiatric
- Anxiety
- Confusion
- Depression
- Memory loss
- Panic Attacks
- Phobias
Integumentary
- Hives
- Itching
- Rash
- Sores
Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, L.L.C.

Scheduling and Billing Policies

"No Show Policy"

Missed appointments without prior notification are considered "No Show" appointments. In the event of the first No Show, you will receive a letter of notification advising you of the No Show. The No Show will be documented in your account ledger and chart. In the event of Two No Shows or missed appointments, Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, LLC, will no longer provide patient care services either in the Clinic, Endoscopy Center, Hospital or Emergency Room setting. The patient will be advised of the discharge by a certified letter.

"Confirmations"

Please confirm your consultation appointment to avoid cancellation. You will receive a reminder telephone call from our office several days prior to your appointment in which we will advise you that you must confirm your appointment. Please call 465-4573 by 4:00 pm 3 days prior to the appointment or the appointment will be cancelled. If we do not receive medical records by 3:00 pm 2 days prior to the appointment, the appointment will be cancelled.

"Reschedules and Cancellations"

We track cancellations and reschedules. If you reschedule or cancel more than 3 times in one year you may not be allowed to reschedule a visit.

"Late Arrivals"

Late arrival for a scheduled appointment leads to inadequate time to accommodate the remaining patients on the schedule. As such, late arrivals of greater than 10 minutes may not be able to be seen depending on the time available. In addition, those patients who are on the schedule and here at the assigned time will be seen first. We will try to accommodate late appointments if time permits.

"Billing"

Gastroenterology Specialties and Lincoln Endoscopy Center require Deductibles, Coinsurance and Copays to be paid at the time of the visit. This will be collected at the reception desk at check in. Our office will check your insurance benefits and call you prior to your visit to discuss them with you. It is your responsibility to be aware of the limits of your insurance benefits. Once your insurance has paid, you will become responsible for any balance due. Payment is expected within 30 days of billing. If you are unable to make payment in full at the time of service, payment arrangements must be made prior to the visit. If requests for payments fail to settle an overdue balance, your account may be referred to a collection agency. If you do not have medical insurance and are self-pay, you will be expected to pay for the visit at the time of service.

"Repeat Exams, Tests and Procedures"

After a thorough initial work up by our physicians, it is sometimes necessary to repeat certain exams, tests, or procedures you might have already had done by your primary care or referring doctor.
Terms & Conditions*
- I have read the Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, L.L.C. Scheduling and Billing Policies and I agree to the terms.
HIPAA 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:
Please list "self only" or names of family members/other persons you wish to disclose your Protected Health Information. I understand that I have a right to revoke this authorization at anytime in writing or by filling out a new disclosure.
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's Signature or Responsible Party*
By typing your name, you agree to all agreements found in this form.
Today's Date*
mm/dd/yyyy

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

Name	Reason	Dosage	Frequency

Name	Reason	Dosage	Frequency

Medication allergic to	Reaction type

1 NDOC Patient Registration Form

Patient's Personal Information

Patient's Insurance Information

Patient / Responsible Party Information

Patient's Referal Information

Emergency Contact Information

Patient History

Family History

Review of Systems

Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, L.L.C.

Scheduling and Billing Policies

"No Show Policy"

"Confirmations"

"Reschedules and Cancellations"

"Late Arrivals"

"Billing"

"Repeat Exams, Tests and Procedures"

HIPAA FORM