Catawba Gastroenterology New Patient Registration

Last Name: First Name: Middle Initial:

Mailing Address:

City: State: Zip:

D.O.B. / / Sex: ❑Male ❑ Female Race: SS#:

Marital Status: ❑ Single ❑ Married ❑ Widowed 0 Divorced Spouse/Partner Name:

Home #: Cell #: Work #:

Emergency Contact: Relationship: Phone #:

Email Address:

Referring Physician: Family Doctor:

Pharmacy: Name Phone Number

INSURANCE INFORMATION

Primary Insurance

Name of Insurance: Are you the insured? ❑ Yes ❑ No

Policy Holder's Name: Policy Holder's DOB: / /

Relationship to Insured: ❑Spouse ❑Child ❑Self ❑Other SS#:

Policy ID Number: Policy Group Number:

Secondary Insurance

Name of Insurance: Are you the insured? ❑ Yes ❑ No

Policy Holder's Name: Policy Holder's DOB: / /

Relationship to Insured: ❑Spouse 0 Child 0 Self ❑ Other SS#:

Policy ID Number: Policy Group Number:

CONTACT PRIVILEGE INFORMATION: I authorize the following persons to obtain medical information (ex: appointment times, test results, billing questions) about myself:

NAME

RELATIONSHIP PHONE NUMBER

Patient Name: Date:

Please check all that apply.

Abdominal Pain _Heartburn in Chest

Chest Pain _Bloating

Other

General Health

_Loss of Appetite _Loss of Weight _Gain of Weight _Fevers/Chills _Leg swelling _Headaches _Seizure Disorder

Other

Nausea/Vomiting _Swallowing Difficulty

Food Allergy _Red Blood in Stool

Diabetes _Asthma/COPD _Sleep Apnea _Endometriosis _Kidney Failure _Amdety/Depression

_Dark Colored Stool _Constipation _Diarrhea

_Strokes _Heart Failure _Heart Murmur _Coronary Artery Disease _High Cholesterol _High Blood Pressure

Previous Surgeries

_Endoscopy Colonoscopy _ Colon Cancer _

_Colon Resection Gallbladder _Bowel Obstruction _Hemorrhoids

Other

Family History

_Colon Cancer _Crohn's Disease _Breast Cancer _Pancreatic Cancer

Ulcerative Colitis _Uterus Cancer _Esophagus Cancer _Celiac Disease/SPRUE _Liver Disease

Social History

Do you drink alcohol?

No. of drinks per week Are you a current smoker?

If you smoke, how many packs per day?

Are you a former smoker?

If so, when did you stop? No. of years smoked?

Do you take Goody or BC Powders?

Current list of Medications (Prescription and over the counter):

Medication Allergies:

_Stomach Ulcer _Liver Biopsy _Gastric Bypass _ _Hysterectomy

Appendectomy _Tubal Ligation _Cesarean Section _Coronary Stents _Coronary Bypass

Catawba Gastroenterology, PA 108 Healthcare Drive • Lancaster SC 29720 • (803) 286-9963

Patient Name: Date of Birth:

Financial and Payment Policy

Thank you for choosing Catawba Gastroenterology. We are committed to providing you with the highest quality and affordable health care. Because some of our patients have had questions regarding

patient and insurance responsibility for services rendered, we have implemented this payment policy.

Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1. Insurance — We participate in most insurance plans, including Medicare and Medicaid. If you do not have insurance or are insured by a plan we do not

participate with, payment in full is expected at each visit. If you are insured by a plan we do participate with but don't have an up-to-date card, payment in full for

each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Authorizations — If your insurance plan requires a referral or an authorization to be

seen in our office, it is your responsibility to obtain this information prior to your visit. If you do not obtain this information or we have not received it from your

referring physician before you arrive for your scheduled appointment, you will be

rescheduled. Your insurance will not cover your services in this office without the referral or authorization.

3. Co-Payments and deductibles — All copayments and deductibles must be paid at the

time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients

can be considered fraud. Please help us in upholding the law by paying your co-

payment at each visit. For your convenience Catawba Gastroenterology accepts

cash, check, Visa, and MasterCard.

4. Non-Covered services — Please be aware that some and perhaps all of the services

you receive may be "non-covered" or not considered reasonable or necessary by

your insurance plan, Medicare and Medicaid. You must pay for these services in full

at the time of your visit. There are also certain administrative services, such as

completing disability or FMLA forms, which require the physician's time, just like a patient visit does. Therefore, as outlined in #9 below, there are certain

administrative services that are not covered by your insurance and are your

responsibility directly.

5. Proof of Insurance — All patients must complete our patient information form, if

necessary, before seeing the doctor. We must obtain a copy of your driver's license

and a current valid insurance card to provide proof of insurance. If you fail to provide us with the correct information in a timely manner, you may be responsible for the balance of a claim.

6. Claims Submission — We will submit your claims and assist you in any way we reasonable can to help get claims paid. Your insurance company may need you to

supply certain information directly. It is your responsibility to comply with their

request. Please be aware that the balance of your claim is your responsibility

whether or not your insurance company pays your claim.

Financial and Payment Policy - continued

7. Coverage changes — If your insurance changes, please notify us before your next visit

so we can make the appropriate changes to help you receive your maximum

benefits.

8. Nonpayment — If your account is over 90 days past due, you will begin receiving monthly collection letters. Please be aware that as long as your account is

outstanding you will not be able to schedule any appointments until the balance is

paid in full.

9. Missed Appointment — Our policy is to charge a $25 fee for missed appointments and

a $50 fee for missed procedure appointments (EGD and Colonoscopy) not canceled

within 24 hours (1 business day) of the appointment time. These charges will be your

responsibility and billed directly to you. This charge will have to be paid before

another appointment can be scheduled. Please help us to serve you and all of our

patients better by keeping your regularly scheduled appointment. If you have three

(3) No Show Appointments on your account, our practice will be unable to schedule your next appointment without a new referral from your primary care physician.

10. Payment Agreement — I understand and agree that, regardless of my insurance status, I am ultimately responsible for any and all charges related to my diagnosis and

treatment, whether or not my insurance covers these services. I agree to pay IN FULL within 30 days of receipt of a notice of any patient balances due. In addition to fees

for non-covered services, co-pays, and or deductibles, I agree to pay when billed for

non-covered administrative fees, when appropriate, as outlined.

a. Returned check fee of $25.00

b. Appointment no-show fee $25.00

c. EGD or Colonoscopy no-show fee $50

d. Records Request, Disability, Family Medical Leave Act (FMLA), or other insurance related form completion fee of $25

Our practice is committed to providing the best treatment to our patients. Our prices are representative

of the usual and customary charges for our area. This Financial and Payment Policy may be updated or

revised from time to time. You may request a copy of this policy at any time to review and to ensure you

have the most recent version. Thank you for understanding our payment policy. Please let us know if

you have any questions.

I have read and understand the payment policy and agree to abide by its guidelines:

Signature of patient or responsible party Date

If Responsible Party (Guarantor), Print Name Relationship to Patient

Catawba Gastroenterology, PA

Hipaa Privacy Policy

I, , hereby Authorize Catawba Gastroenterology PA to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment, and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Catawba Gastroenterology PA can refuse to treat me.

I understand I can request a copy of the Notice of Privacy Stand ("Notice") which more fully describes the uses and disclosure that can be made of my individually identifiable health information for treatment, payment, and health care options.

I understand that I may revoke this consent at any time by notifying Catawba Gastroenterology PA, in writing, but if I revoke my consent, such revocation will not affect any actions that Catawba Gastroenterology PA took before receiving my revocation.

I understand that Catawba Gastroenterology PA has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request.

I understand that I have the right to request that Catawba Gastroenterology PA restricts how my individually identifiable health information is used and/or disclosed to carry out my treatment, payment, or health operations. I understand that Catawba Gastroenterology PA do have to agree to such restrictions, but that once such restrictions are agreed to, Catawba Gastroenterology PA must adhere to such restrictions.

Signature of patient or patient's representative Date

Printed name of patient or patient's representative

Relationship to patient

Catawba Gastroenterology, PA 108 Healthcare Drive • Lancaster SC 29720

Phone (803) 286-9963 • Fax (803) 283-6330

Authorization for Release of Medical Information

Patient's name, Date of Birth.

Address.

City/State/Zip Code,

SS#, Phone#,

OR

171 I authorize Catawba Gastroenterology. PA

to release information to

❑ I authorize Catawba Gastroenterology, PA

to obtain information from,

Name of Provider or Facility

Name of Provider or Facility

Address

Address

City. State. Zip Code

City, State, Zip Code

Phone#/Fax# (include area code) Phone#/Fax# (include area code)

TYPE OF RECORDS REQUESTED. (Check One)

❑ Treatment summary (includes history/physical. laboratory test & x-ray results, operative reports, and pathology)

❑ Specific information

0 Procedure Reports ❑ History & physical 0 Laboratory test results 0 X-ray reports

0 Pathology Reports ❑ Other

❑ Entire copy of my records (Please Describe)

I understand that,

• My right to healthcare is not conditioned on this authorization.

• I may cancel this authorization at any time by submitting a written request to the address provided at the top

of this form, except where a disclosure has already been made in reliance on my prior authorization.

• If the person or facility receiving this information is not a health care or medical insurance provider covered

by privacy regulations, the information stated above could be re-disclosed.

• Release of HIV/AIDS related information, mental health related care, or substance abuse diagnosis and

treatment information will be included as a part of my medical record to the above named person/facility.

Signature of Patient or Representative Date.

Relationship to Patient (if requestor is not the patient)

Your health is in your hands...

with he alow

Your health & online wellness platform

Catawba Gastroenterology Online Patient Portal Information

Our patient portal is a secure online website that gives patients convenient 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can view health information such as:

• Recent doctor visits • Discharge summaries • Medications • Allergies • Lab results

Our patient portals also allow patients to:

• Exchange secure e-mail with their health care teams • Request prescription refills • Schedule non-urgent appointments • Update contact information • Download and complete forms • View educational materials

If you are interested in signing up, please provide us with your email address. Please be sure to complete the email address on the patient demographic form and give it to our receptionist and we will get you signed up today. Once you sign up with us, you will receive an email from Eclinical Works. Inside the email will be a link that you will need to follow to complete your registration. You will use your email address as your username and you will need to create a secure password.

You can also access your patient portal with your mobile device or tablet. Once you have setup your account online, you can download the Healow Application through your app store to access your medical information from anywhere.

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