Pre Procedure Form Pre Procedure Patient Form Patient's Personal InformationName* First Last Middle InitialMarital Status*SingleMarriedDivorcedWidowedSex*MaleFemaleRace*White / CaucasionBlack or African AmericanAsianHispanic or LatinoAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslandMixedOtherUnkownPatient Declines to Provide InformationEthnicity*Hispanic or LatinoNot Hispanic or LatinoPatient Declines to Provide InformationLanguage*EnglishFrenchGermanItalianJapanesePortugeseRussianSpanishOtherAddress*If apartment or suite, indicate in Address Line 2 Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Social Security Number #Date of Birth*Cell Phone/Main PhoneOther Phone NumbersBest time/days for Nurse to call:Calls are made Monday-Friday 8:30AM-4:00PMEmployer / School NameDate of your procedure Date Format: MM slash DD slash YYYY Email Spouse's NamePrimary Insurance Company's NamePrimary Insurance Company's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Primary Insured InformationName of InsuredDate of BirthRelationship to InsuredPrimary Insurance ID #Primary Group ID # Patient HistoryPlease fill out this information to the best of your ability.Chief Complaint*Screening Colonoscopy (Screening for Colon Polyps only, no history of polyps)Follow up Colonoscopy (Personal history of colon polyps )Diagnostic Colonoscopy (Active GI symptoms wanting the procedure to diagnose)EGDHave 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.Prescription Medications*NameReasonDosageFrequency Over the counter Medications/Vitamins*NameReasonDosageFrequency Medication Allergies* I do not have any medication allergies I am allergic to latex I have other allergies to list Other AllergiesLeave blank if no other allergiesMedication allergic toReaction type Surgical History*Surgery typeDate *Please select one Past Blood Transfusion? Complications with Sedation/Anesthesia? Not applicable Explain your complications with sedation/anesthesia.*Alcohol Use?* None Social use/Daily use Recovering Alcoholic How many drinks per week or per day, please specifyDate you quit drinkingTobacco Use* Never Smoker Former Smoker Current Smoker Cigarettes per dayYear QuitRecreational Drug Use* Never used Previous drug use Current drug use List of drugs and year quitList current recreational drugs useCaffeine Use Coffee Tea Soda Energy Drinks None Caffeine UseCaffeine typeDaily Amount Family HistoryHas 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 DiseaseColon 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 SystemsPlease check any that apply to youConstitutional 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 Not applicable Gastrointestinal* Abdominal pain Change in appetite Change in bowel habits Constipation Diarrhea Diverticulitis Diverticulosis Heartburn Hemorrhoids Hepatitis Indigestion Inflammatory Bowel Disease Jaundice Nausea Pancreatitis Colon polyp or tumor Rectal bleeding Trouble swallowing Ulcer Vomiting Not applicable How frequently do you have bowel movements?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 HIPPA FORMPlease 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 ResponsibilityPatient 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 FilingWe 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. 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 ResponsibilitiesPlease 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* MM DD YYYY 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.CommentsThis field is for validation purposes and should be left unchanged.