Catawba Gastroenterology PA
108 Healthcare Dr
Lancaster SC 29720
803-286-9963
1380 Ebenezer Rd St E
Rock Hill SC 29732
803-283-6330
Open Access Screening
The Open Access Colonoscopy Program makes this important screening procedure more
accessible to everyone. The program allows healthy patients without significant
symptoms to have a colonoscopy without the inconvenience of a preliminary office visit.
It is considered to be a safe and appropriate for the right patients and there are many
groups across the country with similar programs.
Please complete the medical questionnaire and send it to us. The questionnaire will be
reviewed in our office to ensure that you do not need a preliminary office visit. You will
be contacted and set up for either a colonoscopy or an office visit. Participation in the
Open Access Program is contingent upon pre-procedure insurance approval.
Colon Cancer Screening
“Screening” is a test for the early diagnosis of common cancers before symptoms
develop. Colon cancer is now the second leading cause of cancer deaths in the US and is
equal in both men and women. The current recommendation for colon cancer screening
by the American Cancer Society is a colonoscopy at age 50 (45 for African Americans
due higher risk at earlier age). Future exams are planned on the findings and family
history of colon cancer. If a screening colonoscopy is normal the next exam would be
recommended in 10 years unless there is a family history of colon cancer or new
symptoms.
Colonoscopy?
A colonoscopy is the procedure recommended by the American Cancer Society for colon
cancer screening.
The day before the exam , you will follow a clear liquid diet: otherwise the days activities
are unrestricted. That evening you will take medication to induce diarrhea to cleanse the
colon for the next day’s exam. At midnight you will stop drinking liquids until after the
procedure.
The next morning you will report to the designated facility where an IV is started and you
are sedated in a monitored setting for the procedure. The procedure is passage of a
flexible thin tube with a camera on the tip through the large intestine or colon for
inspection and removal or biopsy of polyps or abnormal growths. Following the exam
and a short recovery period you are discharged home with your escort and are instructed
to relax the rest of the day.
The next day, typically there are no restrictions and you may return to normal activities.
Catawba Gastroenterology PA
108 Healthcare Dr
Lancaster SC 29720
803-286-9964
1380 Ebenezer Rd St E
Rock Hill SC 29732
803-283-6330
Open Access Screening Questionnaire
Name_________________________________________________________________
Date of Birth__________________________Social Security Number______________
Address________________________________________________________________
City____________________________State__________________Zip______________
Telephone (Daytime)__________________________ Mobile_____________________
Primary Care Doctor ____________________Referring Doctor___________________
Insurance Carrier______________________Insured Name_______________________
Policy #_________________Group #_______________Insured SS#_______________
Relationship to Insured__________________ Insured Date of Birth________________
Insurance Customer Service Phone Number ___________________________________
**Please include copy of insurance card, front and back with completed paperwork**
List all active medical problems_____________________________________________
_______________________________________________________________________
List all medication (include over the counter products)___________________________
_______________________________________________________________________
Allergies to medications___________________________________________________
Please answer the following medical history questions by circling Yes or No.
Heart Disease
Yes
No
Yes
No
Yes
No
Lung Disease
Yes
No
Yes
No
General Health
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Coronary Artery Disease / Angina / Heart Attack
Congestive Heart Failure
Valvular Heart Disease
Emphysema, COPD, Asthma, Bronchitis requiring regular medical therapy
Sleep Apnea
Kidney Failure
Stroke
Diabetes
Do you take antibiotics before dental work?
Have you had joint replacement within the last year?
Have you ever had a complication with anesthesia?
Gastroenterology
Yes
No
Do you heartburn more than twice a week?
Yes
No
Do you see blood in your bowel movements?
Yes
No
Do you have frequent constipation or diarrhea?
Yes
No
Do you have relatives with colon cancer? Who?_______________________________
Yes
No
Do you have a personal history of colon cancer? When?________________________
Release of Medical Records:
I authorize Catawba Gastroenterology to release my health information to the following
entities: Insurance Companies, Disability Companies, Referring Physicians, and any
Doctor Catawba Gastroenterology refers me to.
________________________
Patient Signature
I authorize _____________________________________(referring Doctor)to release any
medical information needed for treatment. ______________________
Patient Signature
Financial Disclosures:
I agree to pay for any and all charges deemed as “patient responsibility” by my insurance
company. All co-pays, deductibles, co-insurances, and deposits for procedures are due at
the time of service. If uninsured, I understand I must make payment arrangements with a
member of the office staff.
___________________
Patient Signature
Please return the completed form to our office. If there are no contradictions you will be
assigned one of our physicians to be set-up for a colonoscopy. You may need a
preliminary consultation if there are medical concerns identified that would need
attention before scheduling your colonoscopy. Your insurance company will be notified
for benefit verification. If you have not heard from our office within 10 days please call
our office (803)-286-9963 and ask to speak to the Open Access Cordinator.
Mail Completed Form to: Catawba Gastroenterology PA, 108 Healthcare Dr, Lancaster SC 29720
Fax Completed Form to: Catawba Gastroenterology PA , 803-283-6330 Attn: Billing Manager
Email Completed Form to: catawbagastroenterology@yahoo.com Subject line : Open Access