Patient Name: Date: Time: FILL OUT ALL PAPERWORK PRIOR TO OFFICE VISIT PLEASE BRING ANY TEST RESULTS (i.e., BLOOD WORK, ULTRASOUND, CT SCAN, MRI SCAN, ETC.) INSURANCE CARD RX CARD REFERRAL IF NEEDED 365 Broad Street, Red Bank, New Jersey 07701 732-842-4294 732-842-9129 Fax 732-842-3854 Website - www.rbgastro.com
REGISTRATION INFORMATION Please completely fill out, date & sign Date *PATIENT NAME: Last First Middle initial BIRTHDATE AGE Male Female EMAIL SS # MARITAL STATUS YOU MUST PROVIDE at least one phone number strictly for Appointment Confirmation calls. No medical information will be discussed. Authorization will remain in effect until our office receives written notification. Please indicate preferences below. Primary Phone Home/Cell /other specify: Yes / No Ok to leave message on phone/with person. Second Phone Home/Cell /other specify: Yes / No Ok to leave message on phone/with person. STREET ADDRESS CITY STATE ZIP How did you hear about our practice? REFERRING PHYSICIAN/ ADDRESS PHONE REFERRING PHYSICIAN/ ADDRESS PHONE PATIENT S EMPLOYER WORK PHONE WORK ADDRESS CITY STATE ZIP PRIMARY INSURANCE POLICY/ID# GROUP# EFFECTIVE If Medicare: Part B Start Date (For Primary or Secondary Insurance) CLAIMS ADDRESS CITY STATE ZIP SUBSCRIBER S NAME (policy holder) BIRTHDATE RELATIONSHIP EMPLOYER ADDRESS CITY STATE ZIP SECONDARYINSURANCE POLICY/ID # GROUP # EFFECTIVE CLAIMS ADDRESS CITY STATE ZIP SUBSCRIBER S NAME (policy holder) BIRTHDATE RELATIONSHIP EMPLOYER ADDRESS CITY STATE ZIP Pharmacy Name/town Pharmacy Phone Prescription Card Rx Card Number MANDATORY FIELDS *IMPORTANT Permission given to call with test results, messages from doctor, biopsies, billing etc. to: This permission will remain in effect until we are notified in writing otherwise. You must provide at least one contact. Myself Phone#: Answering machine: (ok to leave message?)yes / No Other person/s: Relationship: Phone#: Answering machine: Yes /No Other person/s: Relationship: Phone#: Answering machine: Yes /No FOR MEDICARE ASSIGNMENT OF BENEFITS: I request that payment of authorized Medicare benefits be made either to me or on my behalf to Red Bank Gastroenterology Associates for any services furnished me by Red Bank Gastroenterology Associates. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. * PATIENT S SIGNATURE: DATE: FOR ALL OTHER INSURANCE ASSIGNMENT OF BENEFITS: I hereby authorize and instruct any and all insurance companies involved with my healthcare coverage to make payment directly to Red Bank Gastroenterology Associates. This is for the Professional Medical Expense benefits allowable and otherwise payable to me under my current insurance policy as payment towards the total charges for professional services rendered. This payment shall not exceed my indebtedness to the above practice, and I have agreed to pay in current fashion any balance if said professional service charges are over and above this insurance portion of payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any of information pertinent to my case to my Insurance Company or adjuster involved in the case, unless I have made alternative arrangements with respect to this data: * PATIENT S SIGNATURE: DATE: Red Bank Gastroenterology Assoc., P.A 365 Broad Street, Suite 1E, Red Bank New Jersey 07701 732 842 4294 Fax 732 842 3854 Endoscopy Center of Red Bank 365 Broad Street, Suite 2E, Red Bank, New Jersey 07701 732 842 9129 Fax 732 842 0172 Website - www.rbgastro.com Rev. 2-24-14 DW/SM/BW
PRIVACY PRACTICES ACKNOWLEDGEMNET AND CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS I,, hereby authorize RED BANK GASTROENTEROLOGY ASSOCIATES to use and disclose my health information, which specifically identifies me or that 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, RED BANK GASTROENTEROLOGY ASSOCIATES can refuse to treat me. I have been informed that RED BANK GASTROENTEROLOGY ASSOCIATES has prepared a notice ( Notice ) that more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment, and healthcare operations. I understand that I have the right to review such Notice prior to signing this consent. I understand that I may revoke this consent at any time by notifying RED BANK GASTROENTEROLOGY ASSOCIATES in writing, but if I revoke my consent, such revocation will not affect any actions that RED BANK GASTROENTEROLOGY ASSOCIATES took before receiving my revocation. I understand that RED BANK GASTROENTEROLOGY ASSOCIATES 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 RED BANK GASTROENTEROLOGY ASSOCIATES restricts how my individual identifiable health information is used and/or disclosed to carry out treatment, payment, or health care operations. I understand that RED BANK GASTROENTEROLOGY ASSOCIATES does not have to agree to such restrictions, but that once such restrictions are agreed to, RED BANK GASTROENTEROLOGY ASSOCIATES must adhere to such restrictions. Signature of patient or patient s representative Printed name of patient or patient s representative Date Relationship to patient APPOINTMENT CANCELLATION/NO SHOW POLICY Red Bank Gastroenterology and the Endoscopy Center of Red Bank requires notice for a cancelled appointment. It is not our intent to inconvenience any of our patients, but in order to run our office as efficiently as possible we need to utilize canceled appointments for other patients. If you are unable to keep your Office Appointment a 24 hour notice is required. If you are unable to keep your procedure appointment two business day notice is required. There will be a $75 charge for missed office appointments. There will be a $300 charge for a missed procedure. Signature of patient or patient s representative Printed name of patient or patient s representative Date Relationship to patient
Page 1 of 7 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Contact Preference Patient Portal Letter Cell Phone All Methods Patient declines to specify Race Select one or more White Unknown Black or African American Patient declines to specify Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Patient declines to specify Sex Male Female Other Preferred Language English Spanish; Castilian Patient declines to specify Allergies Patient has no known allergies Patient has no known drug allergies Penicillins Codeine Morphine Sulfa Bactrim
Page 2 of 7 Milk Nsaids (Non- Steroidal Anti- Inflammatory Drug) Aspirin (Tartrazine Only) Propofol Analogues Kiwi Eggs Peanuts Latex Adhesive Band-Aids Iv Dye, Iodine Containing Contrast Media
Page 3 of 7 Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Pharmacy Name Address Phone Current Medications Name Dose How taken? Immunizations Hep B HPV Hep A, adult MMR Flu vaccine varicella Tetanus Pnuemovax Diagnostic Studies/Tests EGD Colonoscopy ERCP CT Abdomen/Pelvis Abdominal Ultrasound MRI Abdomen/Pelvis Small Bowel Imaging EUS Sigmoidoscopy Previous Procedures Hysterectomy Appendectomy Aneursym Clipping Obesity Surgery Pacemaker Colon Resection Past or Present Medical Conditions
Page 4 of 7 Acid Reflux Colitis Elevated Liver Function Test Melanoma History Diverticulitis Crohn's Disease Irritable Bowel Syndrome Colon polyp history Sleep apnea Ulcerative Colitis Elevated cholesterol Diabetes Mellitus, noninsulin dependent Colon cancer Heart Attack Hepatitis Celiac Disease Renal Failure Cirrhosis Valvular heart disease Hypertension Diabetes Mellitus, insulin dependent Social History Occupation: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Number Frequency Wine Beer Spirits Caffeine Coffee Tea Intake: Tobacco Smoking Status Current every day smoker Current some day smoker Former smoker Never smoker Smoker, current status unknown Light tobacco smoker Heavy tobacco smoker Unknown if ever smoked Drug Use Uses IV drugs currently Used IV drugs in the past Recreational drug use
Page 5 of 7 Exercise Type Quantity Number Frequency Family Medical History No knowledge of family history No family history of No Known Family HX of Colorectal Cancer Health Status Healthy Ill Seriously Ill Disabled Deceased/At Age Cause of Death Diagnoses Esophogeal Cancer Breast Cancer Barrett's Esophagus Liver Disease Liver Cancer Pancreatic Cancer Stomach Cancer Colorectal Cancer GYN Cancer Personal history of colon polyps Ulcerative Colitis/Crohn's Disease
Page 6 of 7 Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Yes No Reminder Preference I would like to receive preventive care and follow up care reminders. Yes No Reviewed with Patient Parent Guardian Not Present Signature Signature Date
Page 7 of 7 Review Of Systems Cardiovascular chest pain palpitations swelling in the ankles and feet Constitutional fatigue fever loss of appetite weight loss ENMT ear pain nasal obstruction nose bleeds hearing loss Endocrine excessive thirst heat intolerance Eyes loss of vision Gastrointestinal abdominal pain abdominal swelling change in bowel habits constipation diarrhea gas heartburn nausea rectal bleeding stomach cramps vomiting difficulty swallowing Genitourinary dark urine Painful Urination frequent urination Blood in the Urine Irregular Menstrual Cycle Heavy Bleeding During Menses Vaginal Discharge/Hx of STD (for female pts only) Hematologic/Lymphatic easy bruising prolonged bleeding Integumentary itching jaundice rashes Musculoskeletal back pain joint pain muscle weakness Neurological dizziness fainting frequent headaches memory loss Psychiatric anxiety depression Respiratory cough Shortness of Breath excessive sputum coughing up blood wheezing