THIRD AVENUE GASTROENTEROLOGY, P.C.
ERIC H. MORGENSTERN, M.D.
WELCOME LETTER
Dear Patients:
Our Physicians and Staff at Third Avenue Gastroenterology, P.C. would like to take this opportunity to
welcome you to our office. As your providers of health care, we look forward to serving you. We
hope that together, we can build the kind of relationship that will ensure that you receive quality of
care and good service.
In order to maximize your benefits, it is very important that you familiarize yourself with the systems,
policies, and benefits outlined in this letter or ask our courteous staff if you have any questions.
Failure to follow the system and unfamiliarity with your benefits coverage may result in delays in
receiving necessary health care and in unnecessary costs to you.
The following is important information you should know.
HOURS OF OPERATION FOR DR. MORGENSTERN
Office hours are:
9:00 AM to 4:30 PM, call 212-570-2075. Urgent care/after office hours: call office number
We are covered by 24/7 telecommunications answering service.
SCHEDULING APPOINTMENTS
Our appointment desk may be reached at 212-570-2075 from 9:00 AM to 4:30PM Monday - Friday.
Be sure to identify yourself.
If you need to cancel an appointment, please call the appointment desk AS SOON AS POSSIBLE.
YOU HAVE CERTAIN RIGHTS
1. You have the right to be treated with respect, consideration and dignity.
2. You have the right to high-quality medical care delivered in a safe, timely, efficient and
cost-effective manner and the right to be assured that the expected results can be reasonably
anticipated. `
3. You have the right to privacy to the extent possible.
4. You have the right to have your disclosures and records treated confidentially and, except
when required by law, those disclosures and records will not be released without your
approval.
5. You have the right to be provided, to the degree known, complete information concerning
your diagnosis, evaluation, treatment and prognosis.
6. You have the right to copies of your medical records at a nominal cost and, if you request it,
those records will be transferred to another practitioner in a timely manner.
7. You have the right to be informed of all reasonable options or alternatives to care and/or
treatment and of the potential advantages and disadvantages of each including the
advantages or disadvantages and the alternatives to having the procedure performed in an
office or other outpatient facility.
8. You have the right to participate in decisions regarding all aspects care.
9. No procedure or treatment will be undertaken without your informed consent after the
alternatives mentioned in #7, above have been discussed with you.
10. You have the right to refuse diagnostic procedure or treatment and to be advised of the
likely medical consequence of such refusal.
11. You have the right to know all of your rights as outlined above.
12. You have the right to know the conduct expected of you in the facility and the
consequences of failure to comply with these expectations.
13. You have the right to know the services available at the facility.
14. You have the right to know the provisions for after\emdash hours and emergency care.
15. You have the right to know if any of the planned procedures or treatments is part of a
research study and the right to refuse to participate in that study.
16. You have the right to know whether or not your providers are insured.
17. You have the right to know how to go about expressing suggestions to the facility and the
policies regarding grievance procedures and external appeals in the event that you are
dissatisfied with your treatment.
18. You have the right to know the name of your provider.
19. You have the right to know what fees are expected and what the payment policies are.
20. You have the right to know what our provider’s credentials are.
21. You have the right to change providers.
YOU ALSO HAVE CERTAIN RESPONSIBILITIES
1. You have the responsibility to accurately and completely provide all clinical personnel with
the health information they need including any medications you are taking.
2. You have the responsibility to follow the directions of the nurse or physician with regard to
diet and/or medication.
3. You have the responsibility to abstain from using any drugs that have not been prescribed
for you and that you have not revealed to our nurse or physician.
4. You have the responsibility to abstain from the use of alcohol as directed by your nurse or
physician.
5. You have the responsibility to inform the nurse or physician if you do not understand any
directions or you do not understand the course of treatment planned for you.
6. You have the responsibility to timely pay all medical bills which are not in dispute and to
forward to us any monies you receive from any insurance company for our services.
COMPLAINT RESOLUTION
We at Third Avenue Gastroenterology, P.C. strive to provide you with excellent quality of care. We
highly believe in changes to improve, and welcome an opportunity to listen to your suggestions and
complaints. Please contact our office manager, Saul Sanchez or your physician to get further
information on our complaint resolution policy. lf your concern is not resolved, you may contact the
Joint Commission at: 1-800-994-6610.
BILLING & PAYMENT
Please see our scheduler for a list of insurances we accept. Your payment is due at the time services
are rendered. Your co-payment is also due at the time of service rendered.
INVOLVE IN YOUR HEALTHCARE
Everyone has a role in making healthcare safe. Our Physicians, Nurses and Technicians are working
to make your health care safety a priority. You as a patient can play a vital role in making your care
safe by becoming an active, involved and informed member of your healthcare team. So SPEAK UP
S - Speak Up if you have any questions or concerns and if you don\rquote t understand ask again
P - Pay Attention to the care you are receiving. Make sure you are getting the right treatment and
medication
E - Educate yourself about your diagnosis and your treatment plan
A - Ask a trusted family member to be your advocate
K - Know what medications you take and why you take them
U - Use a healthcare facility that provides quality care
P - Participate in all decisions about your treatment
PAIN
Pain is considered to be the fifth vital sign. We as your healthcare provider would like to assist you
with any pain you might possibly have. Prompt, appropriate treatment of pain facilitates a successful
physical exam and enhances your ability to undergo any tests that might be necessary to make an
accurate diagnosis. Please see the pain scale below to determine the quality and intensity of your
pain and let us know.
PHYSICIAN INFORMATION
All of our gastroenterologists are board certified.
Becoming a licensed, board certified physician means meeting the most rigorous training and
continuing education offered in the field of medicine.
Certification of physicians is done by medical specialty boards, recognized by the American Medical
Association (AMA) and the American Board of Medical Specialties (ABIVIS), as a way to tell
consumers that the doctors with this credential have successfully completed approved training and
have passed an evaluation process assessing their ability to provide quality patient care in their
specialty. Board certification is a good indicator that your doctor has made a commitment to
continuing medical education and is keeping up with the latest findings in his or her field.
Board certification in gastroenterology is time—limited, and to maintain their certification, doctors are
periodically reevaluated. They must present evidence of licensure and scope of their practice and
pass an examination every 10 years.
Our anesthesiologist, Bob Kam, M.D. is licensed to practice medicine in the state of New York. He
completed a residency program in anesthesiology at St. Joseph's Hospital in Paterson New Jersey. He
was an attending anesthesiologist at St. Joseph’s Hospital for 3 years prior to joining the staff at
Third Avenue Gastroenterology, P.C.
FACILITY OWNERSHIP DISCLOSURE
Third Avenue Gastroenterology, P.C., is owned and operated by Peter S. Kim, M.D., Eric Morgenstern,
M.D., and Jennifer L. Bonheur, M.D.
Please keep this letter for future reference. Should you have any questions, feel free to call us at
212-570-2075. We look forward to serving you.
Sincerely,
Peter S. Kim, M.D.
Medical Director
Third Avenue Gastroenterology, P.C.
We at Third Avenue Gastroenterology, P.C., are working to make health care safety, a priority. You,
as the patient, can also play a role in making your care safe by becoming an active, involved and
informed member of your health care team.
While you are a patient at Third Avenue Gastroenterology, P.C. we want you to feel comfortable to
do the following:
Expect our nursing staff to introduce themselves when they meet you.
Ask about the purpose of medications you are given, including possible side effects.
Don’t be afraid to tell the nurse or the doctor if you think you are about to receive the wrong
medication.
Expect our clinical staff to have washed their hands.
Make sure your nurse or doctor confirms your identity, that is, asks your name and birth date,
before he or she administers any medication or treatment.
Educate yourself about your diagnosis and planned endoscopic procedure.
Thoroughly read all forms and the consent for endoscopy (colonoscopy, upper endoscopy or
sigmoidoscopy) and make sure you understand them before signing. If you don’t understand,
ask our staff or your doctor to explain them.
Before you leave our facility, be sure that you understand all of the post-procedure
instructions.
Consider asking your companion to ask questions that you may not think of, to help remember
answers to questions you have asked, and to speak up for you if you cannot.
Make sure that your companion understands the type of care you will need when you get
home. Your companion should know what to look for if your condition gets worse and whom
to call for help.
Please speak up if you have questions or concerns, and if you don’t understand, ask again.
Don’t be afraid to ask about safety. Tell your nurse or doctor if something doesn’t seem quite
right.
Participate in all decisions about your treatment.
PLEASE ASK TO SPEAK TO OUR OFFICE MANAGER SAUL SANCHEZ IF YOU HAVE ANY CONCERNS
ABOUT SAFETY.
Third Avenue Gastroenterology, P.C.
1317 Third Avenue, 9th Floor
New York, N.Y. 10021
Colonoscopy and Sigmoidoscopy Discharge Instructions
Sedative medication given for procedures can slow your reaction time and coordination for many
hours. If you receive a sedative medication, it is important for your safety to follow the
instructions below for the remainder of the day:




Be taken directly home from the office and rest. Do not resume normal activities until
tomorrow.
Do NOT drive, return to work or operate any machinery or power tools.
Do NOT make important personal or business decisions, sign any legal papers, or perform any
activity that depends on your full concentrating power or mental judgment.
Do NOT take alcohol or take nerve drugs.
If a treatment is performed during the procedure, there is a slight risk of bleeding. Potential
common effects and treatments following the procedure:


Mild abdominal pain or bloating -— rest, eat lightly, and use a heating pad.
Redness and/or swelling where the IV was ·— apply heat and elevate.
Symptoms to report to .your physician:





Severe abdominal pain or bloating.
Chills or fever above 101 degrees occurring within 24 hours after the procedure.
Large amount of rectal bleeding that does not stop. Small amount of rectal bleeding is not
serious, especially if hemorrhoids are present.
Unable to keep down food or drink.
IV site stays red and swollen for more than 2 days.
In the case of an emergency, please contact the doctor on call or go to the emergency room.
Third Avenue Gastroenterology, P.C.
1317 Third Avenue, 9th Floor
New York, N.Y. 10021
Upper Endoscopy Discharge Instructions
Sedative medication given for procedures can slow your reaction time and coordination for many
hours. If you receive a sedative medication, it is important for your safety to follow the
instructions below for the remainder of the day:




Be taken directly home from the office and rest. Do not resume normal activities until
tomorrow.
Do NOT drive, return to work or operate any machinery or power tools.
Do NOT make important personal or business decisions, sign any legal papers, or perform any
activity that depends on your full concentrating power or mental judgment.
Do NOT take alcohol or take nerve drugs.
If a treatment is performed during the procedure, there is a slight risk of bleeding. Potential
common effects and treatments following the procedure:



Mild sore throat —treat with throat lozenges and gargle with warm salt water.
Mild abdominal pain or bloating -— rest, eat lightly, and use a heating pad.
Redness and/or swelling where the IV was ·— apply heat and elevate.
Symptoms to report to .your physician:







Severe sore throat or inability to swallow and/or eat usual diet
Chills or fever above 101 degrees occurring within 24 hours after the procedure.
Pain in chest or neck
Severe continuing abdominal pain, nausea, vomiting, or bleeding
Swelling to the neck area.
Persistent black bowel movements (may indicate hidden blood)
IV site stays red and swollen for more than 2 days.
In the case of an emergency, please contact the doctor on call or go to the emergency room.
THIRD AVENUE GASTROENTEROLOGY, P.C.
PRE-PROCEDURE ANESTHESIA EVALUATION
PATIENT QUESTIONNAIRE
Patient Name: ___________________
Planned Procedure:
_______________________________
Please list ALL PAST SURGERIES:
________________________________
________________
Anesthesia problems:
Yes
No
If Yes, please list:
_______________________________
Please list ALL MEDICATIONS, including
DOSAGE:
________________________________
________________
List any ALLERGIES
(medications/food/inhalant):
________________________________
________________
Do you smoke?:
Yes
No
Did you previously smoke?:
Yes
Packs per day: ____ for ____ years
Quit ____
No
Do you drink alcohol?:
Yes
No
Number of drinks per week: ____
Do you use recreational drugs?:
No Please list:
___________________
How often:
___________________
Yes
Please list any non-prescription
medications: (e.g., cold tablets, vitamins)
________________________________
_________________
Please list any HERBAL: (e.g., Cava-Cava,
Gingo, Ginseng, St. John’s wort,
Echinacea)
________________________________
_________________
Surgeon: _________________________
Please check any symptoms you have
recently experienced:
Fever/chills
Weight loss
Weakness
Fatigue
Pain (identify location):
___________________________
Please list ALL YOUR medical conditions:
Anxiety
Pacemaker
Arthritis
Palpitations
Asthma
/irregular heart
Bleeding problems
Pneumonia
Bronchitis
Reflux
Chest pain
Seizure
COPD
Shortness of
Depression
breath
Diabetes
Sickle cell
Excessive bruising
Sleep apnea
Glaucoma
Stoke
Heart Attack
TB
Heat/Cold problems
Thyroid
Hiatal hernia
disease
High blood pressure
Ulcer
Kidney disease
Urinary
Liver disease
problems
Family History of Medical Conditions:
Asthma
High blood
Cancer
pressure
Diabetes
Stroke
Emphysema
Other:
Heart
___________
Famlly History of Anesthesia
Complications: ___________________
List your primary care physician:
Name: ___________________
Address: ___________________
Telephone: ___________________
Third Avenue Gastroenterology, P.C.
1317 Third Avenue, 9"' Floor
New York, NY 10021
Tel: 212-570-2075
Fax: 212-570-2038
Saul Sanchez
Office Manager
PLEASE CHECK OFF EACH ITEM THAT APPLIES TO YOU THEN PRINT AND SIGN YOUR
NAME
I confirm that I have been given and explained the instructions for my
scheduled colonoscopy/upper endoscopy/sigmoidoscopy and have
been given the opportunity to ask questions.
I have been instructed to bring an escort or have someone pick me up
at the conclusion of my visit.
I have been given a written copy of the discharge instructions and
understand I should call the office immediately if I experience any
difficulty related to my procedure.
I have completed the Anesthesia Evaluation form given to me.
I have received the Welcome Letter from Third Avenue Gastroenterology, P.C.
PRINT NAME: _____________________________
PATIENT SIGNATURE: _____________________________
TODAY’S DATE: ________________
STAFF SIGNATURE: _____________________________