Orlando Gastroenterology, P.A.
Name _________________________________ Date ________________Marital Status _____________
SSN # __________________ Home Phone ____________________ Birth Date____________________
Home Address _______________________________________________________________________
City _______________________ State ________________ Zip __________________ Sex: M or
Employer _______________________________
F
Occupation ________________________________
Email Address _______________________________________________________________________
Cell _____________________ Work ___________________ Emergency Contact ____________________
Pharmacy Info
Pharmacy Name: ________________________________________
Address: __________________________________________
Phone: ___________________________________________
Patient Acknowledgement: I understand I have the right to accept and refuse medical treatment and to exercise my right
and implement an “Advanced Directive,” refers to any legal document that informs family members and medical
personal how you wish to be treated if you are hospitalized and cannot communicate your wishes. Please check the
following statements that apply:


I Have Not executed an Advanced Directive
I Have executed an Advance Directive
 Living Will
 Durable Power of Attorney
 Do Not Resuscitate (DNR) Order
 Designation of health care surrogate form
Location of Form____________________
Designee/Guardian__________________
Signature_________________________ Witness_________________________ Date_________________
Insurance Assignment & Release Form: I Hereby authorize my Insurance Benefits to be paid directly to Orlando
Gastroenterology, P.A. I also authorize the physician to release any information required and/or requested by insurance
carrier. Office policy: I understand that I am responsible for insurance deductibles, co-pays and percentages as per my
insurance policy. I understand all fees are due at the time services are rendered. I understand that here is a $15 dollar
charge on all returned checks and a $25 dollar charge for confirmed appointments cancelled without 24 hours prior
notice or failure to show up for a scheduled and confirmed appointment. I also understand that Orlando
Gastroenterology, P.A. files claims to the insurance company as a courtesy, and that I am responsible for any service
the insurance company does not pay for.
Signature _____________________________________________ Date ___________________________
Orlando Gastroenterology, P.A.
ACKNOWLEDGEMENT FORM
I have received the Notice of Privacy Practices and have been provided an
opportunity to review it.
With my consent, Orlando Gastroenterology, P.A. may call home or
designated location and leave a message on voice mail, answering machine
or with family member___________________________________________
(DOB) _____________________; in reference to any items that assist the
practice in carrying out TPO (treatment, payment, and healthcare operations)
such as appointment reminders, insurance items and calls pertaining to my
medical care, including laboratory results, etc.
Name _____________________________Birth date _________________
Signature _____________________________________________
Date _________________________________________________
Sri Pothamsetty, MD.
Orlando Gastroenterology, P.A.
Date _____________________
Patient Name _____________________________________________________________________
DOB: ______________________ S.S.N# __________-_________-_________ Phone: _______________________
Patient Address _________________________________________________________
_________________________________________________________
I herby authorize _________________________________________to release medical information to:
Name:
Address:
Phone:
Orlando Gastroenterology, P.A.
1507 S. Hiawassee Road, Suite 105
Orlando, FL 32835
407-445-9224
Fax: 407-445-6236
SPECIFIC DOCUMENTS TO BE RELEASED:
( ) ALL Records
( ) Pathology Report(s)
( ) Discharge Summary
( ) History/Physical
( ) Procedure Report(s)
( ) Consultation
( ) Labs
( ) Radiology Reports
( ) Progress Notes
( ) Physical Orders
( ) Nurse Notes
( ) Medications
( ) Psychiatric
( ) HIV/AIDS
( ) Drug/Alcohol
( ) Specified Date(s)of service __________________________
( ) Hand Carry
( ) Mail
( ) Fax
PURPOSE FOR INFORMATION:
( ) Continued Medical Care
( ) Insurance
( ) Personal
This request is authorized to include any federal and/or state protection under Florida Statutes 394.459(9)
Psychiatric Information, 397.053/396.112 Drug and Alcohol Abuse Information, 381.609 HIV and AIDS related
conditions and/or 397.50(3) records of minor client.
NOTICE TO REQUESTING PARTY: Florida statue has established guidelines and cost rates for the copying of
records. Your signature on this form indicates your knowledge of this statement.
I understand that any disclosure of information carries with the potential for an unauthorized redisclosure and the
information may not be protected by federal confidentially rules.
I hereby release Orlando Gastroenterology, P.A. and their employees, agents, officer, and affiliates, from any and
all liability, responsibility, claim and damages, which may result in the release of information authorized by the
consent for release of information.
Sign:______________________________________________ Date:_____________________________
(If not patient, state relationship)
Form of ID verified_____________________________________________________________________
Witness: ___________________________________________ Date: _____________________________
1507 South Hiawassee Road Suite 105 Orlando, FL 32835
Phone: (407) 445-9224
Fax: (407) 445-6236
Sri Pothamsetty M.D.
Orlando Gastroenterology
1507 South Hiawassee Rd. Suite 105
Orlando, FL. 32835
PH: 407-445-9224
F: 407-445-6236
Medication History Consent
Date _____________________
I __________________________________ hereby give Orlando Gastroenterology consent to
access my medication history through Rx Hub.
Patient Name _______________________________________ DOB: ___________________
Witness: ___________________________________________ Date: ___________________