Patient's Personal Information
If apartment or suite, indicate in Address Line 2
Calls are made Monday-Friday 8:30AM-4:00PM
Date Format: MM slash DD slash YYYY
Please fill out this information to the best of your ability.
Please include type, location of procedure, and year.
If you have a mail order pharmacy and a local pharmacy, please advice which is primary.
Leave blank if no other allergies
Please list any abdominal, heart or lung surgeries, joint replacements, or metal implant/insertions (ie: rods, plates, screws)
Has anyone in your Immediate Family (ONLY Parents, siblings, children) had any of the following?
Review of Systems
Please check any that apply to you
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.
We will file your primary and secondary insurance for you as a courtesy if the following conditions are met:
- The Assignment of Benefits (below) has been signed.
- 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.
Patient Rights and Responsibilities
By typing your name, you agree to all agreements found in this form.
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.
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