Dr. Mark A. Casillas, Jr.
1934 Alcoa Highway, Ste. D370
Knoxville, TN 37920
865-305-5335 / Fax 865-305-8840
Date:
Dear
:
We would like to welcome you to University Colon & Rectal Surgery. We appreciate the trust
you have placed in us. You are scheduled to see Dr. Casillas on
, at
EST.
Please arrive 30 minutes prior to your appointment to allow us to complete your registration. If
you should arrive 20 minutes after your scheduled appointment time above, you may be asked
to reschedule.
Enclosed please find the paperwork needed for your first visit. It is imperative that you bring the
completed paperwork with you to your first visit. We will require you current insurance card and
a driver’s license at each visit. We will also require your co-payment at time of your visit or any
applicable deductible amount. We ask that you prepare for your appointment by doing a Fleet’s
enema one hour prior to your scheduled appointment time.
Our billing is performed a central location, not in our office. The billing office hours are the same
as our office hours, Monday through Friday 8:00 am to 4:30 pm. If you have any billing
questions, please call 865-670-6199.
Parking is available underneath our building. Parking costs $2.00 and is paid as you leave the
parking area. Enclosed is a map to help you find our building and the correct parking area. Use
the elevators directly underneath our building to reach our office on the third floor.
If you have any questions, please feel free to call us at 865-305-5335.
Sincerely,
Tara Pompilio
Patient Service Representative
Mark A. Casillas, Jr., MD specializes in laparoscopic and robotic colon and rectal surgery for neoplastic
and benign disease, transanal endoscopic microsurgery, inflammatory bowel disease including Crohn’s
disease and ulcerative colitis, constipation, and functional anorectal disorders.
Dr. Casillas is an Assistant Professor in the Division of Colorectal Surgery in the University of Tennessee
Graduate School of Medicine Department of Surgery. He received a Bachelor’s in Microbiology from the
University of Alabama. He completed a Master’s degree in Molecular Biology at the University of
Alabama at Birmingham, and earned his Medical Doctorate from the University of Alabama School of
Medicine (UAB). He performed his intern year at Brown University School of Medicine and then
completed his general surgery training at St. Joseph Mercy Hospital, Ann Arbor. Dr. Casillas completed a
subspecialty fellowship in Colon & Rectal Surgery at Indiana University School of Medicine, and joined
the faculty of the University of Tennessee Medical Center in 2012.
Dr. Casillas has written and presented articles and abstracts on a variety of subjects including basic
science cancer research, robotic colon and rectal surgery, as well as single incision laparoscopic colon
and rectal surgery.
Dr. Casillas is board certified by the American Board of Surgery and board eligible for the American
Board of Colon and Rectal Surgery.
Dr. Casillas specializes in the diagnosis and treatment of diseases of the colon, rectum, and anus with
emphasis on screening for colon cancer, the surgical management of colorectal cancer, hemorrhoids,
diverticular disease, and inflammatory bowel disease (Crohn's disease and ulcerative colitis). We offer
state-of-the-art screening for colon and rectal cancers and treat complex anorectal disorders, including
incontinence, pelvic floor abnormalities, anal fissures, and fistulas.
PATIENT REGISTRATION
Date
For Internal Use Only
Patient Number
PATIENT INFORMATION
Social Security #
Date of Birth
First Name
Middle
Last Name
Home Address
City
State
Email Address
Race ______ Ethnicity ____________
Marital Status
Married
Single
Home Phone (
)
(Circle One)
Divorced Widowed
Cell Phone (
)
(Circle One) Employed Retired Disabled
Work Phone (
)
F/T Student Other
Employer
Referring Physician
How did you hear of us?
PRIMARY INSURANCE INFORMATION
PLEASE PROVIDE YOUR INSURANCE CARD TO THE RECEPTIONIST
Insurance
ID #
GR #
Name of Insured
DOB
SS#
SECONDARY INSURANCE INFORMATION
I Insurance
Name of the Insured
ID#
GR #
SS#
DOB
EMERGENCY CONTACT
Relationship
First Name
Home Phone (
Middle
Work Phone (
)
Last
)
Cell (
)
SPOUSE/GUARANTOR/RESPONSIBLE PARTY
Social Security #
Relationship
First Name
Address
Employer
City
Sex
Date Of Birth
Daytime Phone (
)
Middle
Last Name
City
State
Address
State
Zip
Zip
AUTHORIZATION TO RELEASE INFORMATION AND PAY BENEFITS TO PHYSICIAN: I hereby authorize the physician to release any
information acquired in the course of my treatment necessary to process insurance claims. I also authorize payment directly to the
Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his/her services as described, realizing I am
responsible to pay non-covered services.
SIGNATURE (Patient or Parent if Minor)
DATE
Julio A. Solla, MD * Mark A. Casillas, Jr., MD
1934 Alcoa Hwy., Suite D-370
Knoxville, TN 37920
(865) 305-5335 or Fax (865) 305-8840
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
(All sections must be completed)
Patient Name:
SSN:
Date of birth:
Address:
I hereby authorize the release of medical records to University Colon & Rectal Surgeons
Records to be released from:
For the following purpose: Medical Treatment
The authorization will expire on:
Date or Event may not exceed one year
This request and authorization applies to:
All medical records
Health care information relating to the following treatment,
Condition or dates of treatment:
Specific records to be released (eg. Labs, imaging reports, other):
I understand I have a right to revoke this authorization by written notification to the Privacy Officer, except to the extent it has
acted in reliance and thereon before notice of revocation. I understand that any disclosure of information carries with it the
potential for an unauthorized re-disclosure which may not be protected by federal confidentiality rules. I understand that I may
request a copy of this authorization. I understand that I can refuse to sign this authorization and the above-named office may not
condition treatment on my signing of this authorization.
Signature of Patient
Date
Insurance Payment Policy
Thank you for choosing University Colon & Rectal Surgeons. We are committed to providing you with quality and affordable healthcare. Because some
of our patients have had questions regarding patient and insurance responsibility for services rendered, we have developed this payment policy.
Please read it, ask us any questions you may have, and sign in the space provided. A copy of this can be provided to you upon request.
1. Insurance Plans. We are providers with Medicare, most Aetna plans, Beech Street, Blue Cross/Blue Shield, Blue Care, Champus-military only,
Cigna, the Initial Group, Humana, Americhoice Tenncare, United Health and most Medicare Advantage plans. We are not in-network
providers for UHC Secure Horizon. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are
insured by a plan we do business with, but do not have an up to date insurance card, payment in full is required until we are provided with a
current copy of your insurance information. Knowing your insurance benefits is your responsibility. Please contact your insurance company
with any questions that you may have regarding your coverage.
2. Co-payments. All co-payments must be paid in full at the time of service. This arrangement is part of your contract with your insurance
company. Please help us in upholding your agreement by paying your co-payment at each visit.
3. Non-Covered Services. Please be aware that some of the services you receive may be non-covered or not considered reasonable or
necessary by your insurance, even though your physician feels that it is necessary. Our office will file each visit to your insurance company. If
they deem that something is not reasonable or necessary, we ask that you submit payment for that item immediately.
4. Proof of Insurance. All patients must complete our patient information form before seeing a physician. We will also ask that you complete
this form once a year. We must obtain a copy of your 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 the claim.
5. Claim submission. We will submit your claims and assist you in any way we can to help get your claim 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. Your insurance benefit is a contract between you
and your insurance company. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.
If you have Medicare, we will bill you any money’s owed after we have received payment from Medicare and/or a secondary policy that you
might have.
6. 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. We will also need to have a copy of your new insurance card.
7. Non-Payment. If your account is over 90 days past due, you will receive a letter from our billing department. Partial payments are accepted
as long as you call them directly to set up the necessary payment plan. Please be aware that if a balance remains unpaid, we may refer your
account to a collection agency.
Our practice is committed to providing the best treatment to our patients. Thank you for understanding our payment policy. Please let us know if you
have any questions or concerns.
I have read and understand the payment policy and agree to abide by all guidelines:
_________________________________________
Signature of Patient or Responsible Party
_____________________
Date
Patient Privacy Questionnaire
1934 Alcoa Highway, Suite D-370
Knoxville, TN 37920
Patient Name:________________________________________________
1. May we leave confidential messages with anyone answering the telephone at your home?
Yes
No
2. May we leave confidential messages regarding appointments, return calls for test results, etc. on your
home answering machine or voice mail?
Yes
No
3. May we leave confidential messages with anyone answering the telephone regarding appointments, lab
results or other healthcare information at numbers other than your home number?
Yes
No
If yes, please list number(s) (
)________ - _________; (
)________-__________
4. If we are unable to reach you by any of the above options, may we leave confidential messages at your
place of employment?
Yes
No
5. May we give confidential information to anyone else regarding appointments, lab results or other
healthcare information?
Yes
No
Name:_______________________DOB________________
Relationship:________________________Phone number_________________
Name:_______________________DOB________________
Relationship:________________________Phone number_________________
If we are unable to reach you by any other means, we will send information through the US Postal Service to
your home address.
______________________________________
Signature of patient (or guardian if under age 18)
________________________
Date
I have received a copy of the University Physician Associations Notice of Information Practices. I understand that this Notice describes how my health information
may be used or disclosed by UPA, physicians and other providers practicing at UPA facilities and that I should read it carefully. I am aware that the Notice may be
changed at any time. I may obtain a revised copy of the Notice by call (865) 544-9118, by visiting www.utmedicalcenter.org or by requesting one at a UPA office.
_______________________________________________
Signature of patient (or guardian if under age 18)
_____________________
Date
University Colon & Rectal Surgeons
1934 Alcoa Highway, Suite D-370
Knoxville, TN 37920
865-305-5335 / Fax 865-305-8840
☐Colonoscopy
☐Office Visit
MEDICAL HISTORY QUESTIONNAIRE
Name______________________________ Age_________________
Date__________________
PLEASE PROVIDE THE NAME, ADDRESS, AND PHONE NUMBER OF YOUR PRIMARY CARE PHYSICIAN
PCP:
Date Last seen PCP? ________
Name:
__________________________
Address: ___________________________
___________________________
Phone:
Fax:
___________________________
___________________________
** Which physician referred you to our office?
Please describe 'in your own words' the reason you are seeing the doctor today/ Chief Complaint::
Are you Currently Taking Coumadin, Plavix or TICLID?
☐YES ☐ NO
ALLERGIES
Do you have any drug allergies?
☐YES ☐ NO
Please list which drugs you are allergic to and what happens when you take them.
Please list any allergies to IV Iodine, Contrast or Shellfish (Causing skin rashes or breathing problems (not just nausea/vomiting).
PAST MEDICAL HISTORY
LIST ALL CURRENT MEDICAL PROBLEMS AND PREVIOUS SERIOUS ILLNESSES REQUIRING HOSPITAL WITH DATES:
LIST ALL PREVIOUS SURGERIES AND MAJOR INJURIES WITH DATES OF (unsure of dates please estimate) :
**WOMEN –INCLUDE CHILDBIRTH INFORMATION:
# OF PREGNANCIES
# OF VAGINA DELIVERIES
# OF C-SECTIONS
DATE OF LAST DELIVERY
AGE WHEN FIRST PREGNANT
EPISOTOMY
☐YES ☐ NO
TEARS
☐YES ☐ NO
FORCEPS USED
ANY CURRENT FECAL/BOWEL INCONTINENCE (Stool Leakage)?
HOW FREQUENT: ☐DAILY
☐WEEKLY
☐ MONTHLY
.
☐YES ☐ NO
WHEN DID LEAKAGE START?
.
FAMILY HISTORY
HAVE YOU OR ANY OTHER BLOOD RELATIVES EVER BEEN DIAGNOSED WITH COLON
☐POLYPS ☐ COLON/RECTAL CANCER ☐BOTH
☐NONE
IF YES, WHICH?
☐ FATHER
☐ OTHER RELATIVE
☐ MOTHER
HAVE YOU HAD A TOTAL COLONOSCOPY
DATE OF MOST RECENT COLONOSCOPY:
☐SISTER
.
☐ BROTHER ☐CHILD
☐GRANDPARENT
☐UNCLE ☐AUNT
☐SELF
☐YES ☐ NO
PERFORMED BY:
.
SOCIAL HISTORY
DO YOU USE LAXATIVES?
HOW OFTEN?
☐YES ☐ NO
.
WHAT TYPE?
NUMBER OF BOWEL MOVEMENTS PER WEEK (average)
HOW MANY OF HEM DO YOU STRAIN HARD WITH ☐ NEVER
.
.
☐RARELY ☐ MOST OF THE TIME ☐ ALWAYS
DO YOU SMOKE NOW OR HAVE YOU EVER SMOKED CIGARETTES OR USED ANY TOBACCO PRODUCTS?
IF YES, HOW MUCH?
QUITTING?
ALCOHOL:
PACKS/DAY
YEAR THAT YOU QUIT
☐YES
☐ NO
HOW MANY YEARS DID YOU SMOKE BEFORE
.
☐NEVER
☐ RARELY
☐ MODERATE
☐ DAILY
☐HOW MUCH?
.
REVIEW OF SYSTEMS
DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING: Please check YES or NO
☐YES
☐ NO If yes, how many pounds?
WEIGHT LOSS IN THE PAST YEAR (WITHOUT DIETING)
☐YES
☐ NO Which?
MOUTH OR THROAT SORES/ULCERS
☐YES
☐ NO
HEART/CARDIOVASCULAR DISEASE
If yes, check which type:
☐ Congestive Heart Failure
☐ NO
Are you on fluid restriction? ☐YES
Recently hospitalized for
☐ History of Endocarditis
☐YES
☐ NO
failure?
☐ Artificial Heart Valve
☐ Chest Pain/Angina
☐ Vascular Grafts
When was graft placed?
☐ Coronary By-Pass Surgery
☐ Heart Defibrillator
☐ Coronary Stent
☐ Other heart surgery?
.
Which?
.
☐ Heart Pacemaker
HOME OXYGEN/LUNG OR BREATHING DISEASE
SLEEP APNEA
KIDNEY DISEASE or FAILURE
ORGAN TRANSPLANT
PROBLEMS WITH URINATION?
SWOLLEN OR PAINFUL JOINTS
ARTIFICIAL JOINTS
☐YES
☐YES
☐YES
☐YES
☐YES
☐YES
☐YES
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
What type?
.
ON CPAP MACHINE? ☐YES
☐ NO
ARE YOU ON FLUID RESTRICTION? ☐YES
SKIN CONDITION OR NEW RASH/LESIONS
DIABETES
BLEEDING OR CLOTTING DISEASE
PSYCHIATRIC OR NERVOUS CONDITION
ENLARGED OR TENDER LYMPH NODES
MENSTRUATING (having monthly period)
CHANGE IN BOWEL MOVEMENTS (BM)
☐YES
☐YES
☐YES
☐YES
☐YES
☐YES
☐YES
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
Which
ARE YOU TAKING
RECTAL BLEEDING (even with small amount on
paper.
RECTAL PAIN WITH OR AFTER BM
CONSTIPATION
AWAKENED BY RECTAL PAIN
VAGINAL BULGE WITH BM OR STRAINING
DIARRHEA
ABDOMINAL PAIN
HEMORROIDS COMIN G OUT WITH BM
UNABLE TO CONTROL BM OR
EXCESSIVE MUCOUS WITH BOWEL MOVEMENT
FEELING OF INCOMPLETE EVACUATION
RECTUM COMING OUT/PROLAPSING
RECTAL BURNING/ITCHING OR DISCHARGE
☐YES
☐YES
☐YES
☐YES
☐ YES
☐ YES
☐ YES
☐ YES
☐ YES
☐ YES
☐ YES
☐ YES
☐ YES
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
☐ NO
OTHER COLON, RECTAL OR ANAL PROBLEMS?
.
.
Which type?
Which
What type?
Where?
.
☐
INSULIN
☐
PILLS
.
.
What change?
Bright
☐ NO
Dark
.
Mixed with stool
Straining
Or decreased frequency
How long does pain last?
.
Do you apply pressure on the bulge to have BM?
If yes, how much per day?
.
Where?
Do they stay out?
. Can you push them in?
Which? Gas
. Liquid Stools
. Solid Stools
Do you have to push the rectum back in?
.
.
.
M.D. Notes:
HT
WT
BP
P
T
I reviewed above with patient:
☐Julio A. Solla, MD
☐Mark A. Casillas, Jr., MD
IF SCHEDULING A COLONOSCOPY, PLEASE LIST Thursday DATES YOU ARE NOT AVAILABLE IN THE NEXT TWO MONTHS:
For Office Use Only:
Colonoscopy Scheduled for
Instructions: ☐Given to patient
Scheduled by (initials)
☐Mailed to patient Date:
Medication List
Patient Name:_____________________DOB__________
Allergies
Medication Name
What Pharmacy do you use?
Name:
Address:
Phone:
Directions
Fax: