ilant.
New Patient
TRI-CITIES GASTROENTEROLOGY, P.C.  Information Change
PATIENT INFORMATION
Are you a new patient? __________
Name (last) _________________________ (First) ________________________________ (M.I) ________
Address _____________________________________________________City ____________________________
State ______________ Zip _________________ Ethnicity (Race) _________________ (M/F) __________
SS# __________-_________-____________ Birth Date _________________Age ____________
Home __________________Cell _____________________ Work Phone________________
Would you like to have access to your medical records electronically? Is so please provide us with your email
address.
E-Mail Address _______________________________________________________________________
Marital Status_________________Employer_________________________________________________________
Primary Care Physician _________________________ PCP Phone # ___________________________________
Where do you prefer to be called? (PLEASE CHECK ALL THAT APPLY)
Home______ Work _____ Cell ______
Place to leave confidential information regarding results, appointment times, etc __________________________________
EMERGENCY CONTACT___________________________ Phone ___________________ Relationship__________________
PHARMACY YOU PREFER TO HAVE YOUR PRESCRIPTIONS CALLED INTO? ____________________________________
PHARMACY PHONE ____________________________ PHARMACY FAX __________________________________
PRIMARY INSURANCE
Name of Insurance Company ___________________________________________________________________
Policy Holder _________________________________________________________________________________________________
ID#_______________________________________________ Group#___________________________________
Relationship to policy holder ____________________________________________________________________
Policy holder’s birth date __________________ (M/F) ______
SECONDARY INSURANCE
Name of Insurance Company ____________________________________________________________________
Policy Holder ________________________________________________________________________________
ID#____________________________________________ Group#______________________________________
Relationship to policy holder ____________________________________________________________________
Policy holder’s birth date ________________ (M/F) _________
I, the undersigned, hereby consent to and authorize the administration and performance of
all treatments, the administration of any needed anesthetics; the performance of such
procedures as may be deemed necessary or advisable in the treatment of this patient, the
use of prescribed medications; the performance of diagnostic procedures; the taking and
utilization of cultures and performance of other medically accepted laboratory tests, all of
which the judgment of the attending physician or their assigned designees may consider
medically necessary or advisable.
I fully understand that this consent is given in advance of any specific diagnosis or
treatment. I intend this consent to be continuing in nature even after a specific diagnosis
has been made and treatment recommended. This consent will remain in full force until
revoked in writing.
I hereby authorize Tri- Cities Gastroenterology, P.C. to release medical information to any
of my physicians or insurance companies that may be pertinent to my case. I hereby
authorize payment directly to Tri-Cities Gastroenterology, P.C of benefits otherwise payable
to me. I hereby authorize the release of my medical records to third party insurers or other
authorized persons to whom disclosure is necessary to establish or collect a fee for the
services provided. I understand that I am financially responsible for charges not covered by
this authorization. A photocopy of this authorization shall be considered as valid as the
original. Further, I acknowledge that I am indebted for past due charges and I understand
that I am financially responsible for those charges also. Should this account become
delinquent, I agree to pay all collection and court cost including attorney fees.
MEDICARE PATIENTS: I authorize Tri-Cities Gastroenterology, P.C., to release medical
information about me to the Social Security Administration or its intermediaries for my
Medicare claims. I assign the benefits payable for services to Tri-Cities Gastroenterology,
P.C.
In accordance with the provisions of Section 32.1-45.1 of the Code of Virginia (whenever
any health care provider or any person employed by or under the direction and control of a
health care provider, is directly exposed to body fluids of a patients in a manner which may
according to the current guidelines of the Centers for Disease Control, transmit human
immunodeficiency virus), the patient whose body fluids were involved in the exposure shall
be deemed to the have consented for testing for infection with human immunodeficiency
virus. If there is an exposure and the patient’s test is positive the attending physicians will
notify the patient, and person exposed, and the Virginia Health Department and appropriate
counseling will be offered. I have reviewed and understand my PATIENTS RIGHTS AND
RESPONSIBILITIES. I certify that I have read and fully understand the above statements
and consent fully and voluntarily to its consents.
Patient’s Signature ________________________________ Date: ___________
Notice of Privacy Practices
Patient Acknowledgement
Patient Name: ___________________________________ Date of Birth: _______________
I have received this practice’s Notice of Privacy Practices written in plain language. The Notice
provides in detail the uses and disclosures of my protected health information that may be made
by this practice, my individual rights and the practice’s legal duties with respect to my protected
health information. This Notice includes:
 A statement that this practice is required by law to maintain the privacy of protected health
information.
 A statement that this practice is required by law to abide by the terms of the notice currently
in effect.
 Types of uses and disclosures that this practice is permitted to make for each of the
following purposes: treatment, payment, and health care operations.
 A description of each of the other purposes for which this practice is permitted or required to
use or disclose protected health information without my written consent or authorization.
 A description of uses and disclosures that are prohibited or materially limited by law.
 A description of other uses and disclosures that will be made only with my written
authorization and that I may revoke such authorization.
 My individual rights with respect to protected health information and a brief description of
how I may exercise these rights in relation to:
- The right to complain to this practice and the Secretary of HHS if I believe my
privacy rights have been violated, and that no retaliatory actions will be used against
me in the event of such a complaint.
- The right to request restrictions on certain uses and disclosures of my protected
health information, and that is practice is not required to agree to a requested
restriction.
- The right to receive confidential communications of protected health information.
- The right to inspect and copy protected health information.
- The right to amend protected health information.
- The right to receive an accounting of disclosures of protected health information.
- The right to obtain a paper copy of the Notice of Privacy Practices from this practice
upon request.
This practice reserves the right to change the terms of its Notice of Privacy Practices and to make
new provisions effective for all protected health information that it maintains. I understand that I
can obtain this practice’s current Notice of Privacy Practices on request.
Signature: _______________________________________ Date: _____________________
Relationship to patient (if signed by a personal representative of patient): ________________
Consent to Use and Disclosure of Protected Health Information
Use and Disclosure of Your Protected Health Information
Your protected health information will be used by Tri-Cities Gastroenterology, P.C., or disclosed to
others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care
operations of the practice. In order to provide quality care for you, there may be times where we have to
access your medical records from an area hospital or laboratory facility.
Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your protected
health information may be used or disclosed. You may review the notice prior to signing this consent.
Requesting a Restriction on the Use or Disclosure of Your Information
You may request a restriction on the use or disclosure of your protected health information. Tri-Cities
Gastroenterology, P.C., may or may not agree to restrict the use or disclosure of your protected health
information. If Tri-Cities Gastroenterology, P.C., agrees to your request, the restriction will be binding on
the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a
violation of the federal privacy standards.
Revocation of Consent
You may revoke this consent to the use and disclosure of your protected health information. You must
revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which
your revocation of consent is received will not be affected.
Reservation of Right to Change Privacy Practices
Tri-Cities Gastroenterology, P.C., reserves the right to modify the privacy practices outlined in the notice.
Signature
I have reviewed this consent form and given my permission to Tri-Cities Gastroenterology, P.C., to use and
disclose my health information in accordance with it.
______________________________________
Name of Patient (Please Print Clearly)
______________________________________
Signature of Patient
__________________________________________
Date
______________________________________
Signature of Patient Representative
__________________________________________
Relationship of Patient Representative to Patient
MISCELLANEOUS FEES
We strive to assist our patients in any way possible but some acts take more time than others. To
address this we have implemented an extra fee for certain services. Copies of Medical Records will
incur a $15 charge. Filling out any work related forms (ex: FMLA) will be assessed a fee of $15.00.
Checks returned due to insufficient funds will be charged a $15.00 fee.
Please be aware that by making an initial appointment with our physician, you are agreeing to abide
by the billing policies of our practice. There will be a $25.00 fee billed to you personally, if you do
not provide at least 24-hours’ notice of a cancellation or change in your appointment date or time for
office visits. There will be a $50.00 fee billed to you personally if you do not provide at least 48hours’ notice for cancellation or change in your appointment date or time for procedures. This policy
will be enforced for both new patients as well as established patients.
There are no health insurance policies that cover fees for missed appointments or “No-Show”
appointments.
Please note that we use third party anesthesia companies, there is a possibility that you may be
responsible for any additional fees that your insurance may not cover.
Our staff will be happy to answer any further questions regarding this policy.
___________________________________
(Print Name)
___________________________________
(Sign Name)
___________________________________
(Date)
Patient’s Authorization to Release Medical Information
I understand it is a breech of physician-patient confidentiality for my doctors to discuss my medical
information in any way with anyone without my expressed written consent. By signing this form I am
designating the parties below with whom I wish Tri-Cities Gastroenterology, P.C. to be able to discuss my
medical condition. If I change, my mind regarding the release of information to any of the listed people, it
is my responsibility to inform Tri-Cities Gastroenterology, P.C. in writing of my decision.
In accordance with the above, I ___________________________________________ hereby authorize TriCities Gastroenterology, P.C. to discuss with and release my medical information to the following
individuals:
Name: ___________________________
Phone: ___________________________
DOB: ____________________________
Relationship: _____________________
Name: __________________________
Phone:__________________________
DOB:___________________________
Relationship: ____________________
Name: ___________________________
Phone: ___________________________
DOB: ____________________________
Relationship: _____________________
Name: __________________________
Phone:__________________________
DOB:___________________________
Relationship: ____________________
Name: ___________________________
Phone: ___________________________
DOB: ____________________________
Relationship: _____________________
Name: __________________________
Phone:__________________________
DOB:___________________________
Relationship: ____________________
Name: ___________________________
Phone: ___________________________
DOB: ____________________________
Relationship: _____________________
Name: __________________________
Phone:__________________________
DOB:___________________________
Relationship: ____________________
Patient Signature: _______________________________________ Date:________________________
(SIGNATURE MUST BE PRESENT FOR NAMES LISTED TO BE VALID)