Gastroenterology Stuart H. Coleman, M.D. David M. Dresner, M.D.

James C. Strobel, M.D. Huey T. Nguyen, M.D.

Abdul Jabbar, M.D. Steven P. Harrell, M.D.

HEALTH PARTNERS Matthew D. McCollough, M.D. Emori B. Sizer, M.D.

Dear Patient,

Your primary care physician has referred you to our practice for a procedure. With this letter you will find patient registration, medical history, financial policy and procedure scheduling forms. Please complete the patient registration, medical history and procedure scheduling forms. Sign and date the patient registration, HIPAA and financial policy forms. (We will also need copies, front and back of your current insurance cards.) THESE FORMS WILL NEED TO BE RETURNED TO US IN ORDER TO GET YOUR PROCEDURE SCHEDULED. You may return them in the enclosed envelope, fax them to 812-949-5435 or email them to aprince@ghpsi.com . The completed information may also be brought to our office and you may sit down and schedule your appointment with our scheduling staff at that time. Please be aware the best time to stop in the office would be between the hours of 8:00am-4:45pm, Monday- Friday. If you have any questions concerning these forms, please feel free to call us at 812-945-0145.

After receiving your information, a member of our scheduling staff will use the procedure scheduling form to coordinate your appointment time and instructions to prep for the procedure. Once the nurse has scheduled your appointment, she will mail you information with the date, time, location and instructions. She will include a prescription for the laxatives (for colonoscopies) to be taken to a local pharmacy. The scheduler's name and phone number will be listed on the bottom of your prep sheet if you have any questions concerning the procedure or need to reschedule.

If you provided an email address you will receive an invitation to register for our "Patient Portal" once your appointment has been scheduled. Through the portal you will be able to communicate with us regarding, appointments, billing or clinical questions to your physician including results.

**Once your appointment has been scheduled the insurance staff will check with your insurance company to verify benefits and check for precertification. You will be responsible for any deductibles, co-insurance or co-pays that have

not been met.**

If you have had any recent testing pertaining to your condition or symptoms, we will need copies of those. You may obtain a copy from your physician to give to us, or ask them to fax the records to us at 812-949-5435.

It is very important we get all information requested and that you understand all your instructions. We will make every effort to make your visit as smooth and comfortable as possible. If you have any concerns, feel free to contact the office at 812-945-0145. For more information or directions visit us on the internet at www.ghpsi.com.

Thank you for choosing our physicians to participate in your health care.

Sincerely,

Sammye Wright, CMM, CPC Office Manager

2630 6rant LiM Road, New Albany, IN &7150 {812} 945-0145 www.0hf._iSi.com

Gastroenterology PATIENT DEMOGRAPHIC FORM

dba GASTROENTEROLOGY OF SOUTHERN INDIANA

2630 GRANT LINE ROAD, NEW ALBANY, IN 47150

~ iEAL TH PARTNERS PHONE 812-945..0145, FAX 812-949-5435 www.ghpsi.com

ACCOUNT# LAST NAME: FIRST NAME:

ADDRESS:

CITY: STATE: ZIP CODE:

DATE OF BIRTH: SOCIAL SECURITY#: SEX: MARITAL STATUS:

PHONE NUMBERS: HOME WORK CELL

EMAIL ADDRESS: CAN WE CONTACT YOU BY EMAIL?

EMPLOYER:

SPOUSE/PARTNER: **SOC SEC#: DATE OF BIRTH:

EMERGENCY CONTACT NAME: RELATION: PHONE:

PRIMARY CARE PHYSICIAN: REFERRING PHYSICIAN:

PRIMARY INSURANCE:

ADDRESS:

MEMBER/ID NUMBER: GROUP NUMBER:

PHONE: COPAY: EFFECTIVE DATE:

POLICY HOLDER NAME: DATE OF BIRTH:

EMPLOYER:

SECONDARY INSURANCE:

ADDRESS:

MEMBER/ID NUMBER: GROUP NUMBER:

PHONE: COPAY: EFFECTIVE DATE:

POLICY HOLDER NAME: DATE OF BIRTH:

EMPLOYER:

INSURANCE AUTHORIZATION:

1 request that payment of authorized benefits be made either to me or on my behalf to the above provider for services furnished

by that physician. I authorize release to the indicated insurance carrier any medical information about me needed to determine

these payments for related services. I understand that I am responsible for all fees regardless of insurance.

I siGNATURE: DATE:

**SPOUSE'S SOCIAL SECURITY# MAY BE NEEDED FOR INSURANCE VERIFICATION IF THEY ARE THE POUCY HOLDER.

Ml:

t;ASTROEmtROlOGY flF SOUTHERN ltJOIANA, PL

2630 Grant Line Road New Al-bany, IN 47150 Phone- {812) 94S-o145

Fax - (812) 949-5435

Patient Interview Form

Patient Information A~Name:'--~-----------------------

Last Name: ______________________ _ MRN:, ____________________________ ___ Date Of' Birth:. ________________ _

Race O White/caucasian 0 Black or African

American 0 Native Hawaiian 0 Mixed

or Other Pacific Islander

Ethnicity

0 Asian

0 Other

0 Hispanic or Latino

0 Not Hispanic or 0 Patient declines

Gender

Latino to provide Information

0 Male 0 Female 0 Other

PreferNCI Language 0 English 0 Spanish Other: ____ _

Contact Preference.

0 Hispanic or Latino

0 Unknown

0 Letter 0 Telephone call 0 Email Other: ____ _

Diagnostic Studies{Tests 0 None

C) Labs When: ____ _

Social History

. . 0 Xray/Radiology When: ____ _

0 American Indian or Alaska Native

0 Patient declines to provide Information

occupation:____________________ Number of Children: __________ _

Marital StatiiS

0 Single 0 Married 0 Divorced 0 Separated 0 Widowed

0 Civil Union

Alcohol 0 None

0 Unknown 0 Other

Type Quantity Number Frequency nrnes/ week 0 Alcoholic Drink

Caffeine 0 None

Tobacco Smoking Status

Type 0 Cigarettes

Drug Use

0 None

0

0

Current every 0 day smoker Smoker, current 0 status unknown

Started

current some 0 Former smoker 0 Never smoker day smoker Unknown if ever smoked

Quit Quantity Frequency Ogarettes I Day

Type Quantity Number Frequency Times/ week 0 Recreational Drugs

Exercise 0 None

Previous Procedures 0 None

0 Appendectomy 0 Capsule Endoscopy

0 Colon Resection 0 Colonoscopy

0 Gallbladder 0 Groin Hernia

0 Joint 0 Kidney Replacement

0 Pacemaker/Defibrillator 0 Prostate Surgery

0 Radiation 0 Radiation Therapy- Therapy-Ovary Head/Neck

0 Tubal Ugation 0 Upper/EGO

other:

0

0 0 a

0

0

Past or Present Medical Conditions 0 None

Cardiac (CABG)

Colostomy

Hemorrtloid

Uver Biopsy

0 Radiation Therapy-Abdomen

Radiation Therapy-Prostate Heart Stent Placement

GI Related Illnesses 0 Cirrhosis 0 Colon polyps 0 EsophagitiS/GERD 0 Gallstones

Q Irritable Bowel a Pancreatitis

0 Ulcerative Colitis .::::Ot=h.:.:e,__,r:'--------

Other Illnesses

0 Cardiac (VALVE) 0 Colon Polyp Removal

0 C-Section 0 ERCP

0 Hiatal Hernia 0 Hysterectomy

0 Obesity Surgery 0 Ovary surgery

0 Radiation Therapy-Chest

0 Stomach a Thyroid

0 Artlfldal Heart 0 Dialysis Valve

0 Crohn's Disease 0 Diverticulitis

0 Groin Hernia 0 Hepatitis

0 Stomach/Duodenum Ulcer

0 Abnormal 0 Abnonnal Blood 0 Anemia C) Arterial Bleeding Clotting/Blood Blockages

Clots

0 Blood 0 Breast cancer 0 Chronic Transfusions Headache

0 Chronic Pain for 0 Colon cancer 0 Diabetes 0 Emphysema less than 6 Mellitus months

0 Endometriosis 0 Abromyalgia 0 Frequent 0 Heart Disease Urinary Infections

0 Heart Failure 0 Heart Munnurs 0 High Blood C) High Pressure Chlolesterol

0 HIV/AIDS 0 Irregular Heart 0 Kidney 0 kidney stones Beat Disease/Failure

0 Lupus 0 Melanoma 0 Multiple 0 Osteoporosis SclerosiS

0 Ovarian Cancer 0 Ovarian Cyst 0 Parkinson's 0 Pneumonia Disease

0 Prostate Cancer C) Psoriasis 0 Rheumatic 0 Seizures Fever

0 Sexually 0 Sleep apnea 0 Stroke or 0 TB or Positive Transmitted Paralysis TB Skin Test Disease

0 Thyroid Disease 0 Deep vein thrombosis

0 Pulmonary embolus (blood

0 CVA (stroke)

(blood dot In dot In lung) leg)

0T1A Other:

Immunizations 0 None

0 Au vaccine 0 Hepatitis A 0 Hepatitis B Q HPV 0 Meningococcal

0 Pneumoccocal 0 Tdap

Familr Medical History 0 No knowledge of family history

No family history of O Colon cancer 0 Colon Polyps

~

~ ~ .e

t) )o,. L Cl) .s:

~ G)

~ ~ 01

~ ;:, c: '0 0

E (i) Ill 0 (/)

Health StatUs

AQe/oa~ of Birth

Diagnoses

Family Hx of Colon cancer 0 0 0 0 0 0 Family Hx of Colon Polyps 0 0 0 0 0 0 Family Hx of Celiac Disease 0 0 0 0 0 0 Family Hx of Colitis 0 0 0 0 0 0 Family Hx of Crohn's Disease 0 0 0 0 0 0 Family Hx of Uver Disease 0 0 0 0 0 0 Family Hx of Breast Cancer 0 0 0 0 0 0 F"amlly Hx of Esophageal cancer 0 0 0 0 0 0

Family Hx of Ovarian cancer

Family Hx of Pancreatic Cancer

Family Hx of Stomach cancer

Family Hx of Uterine Cancer

Allers las 0 Patient has no known allergies

b kKitne · · ·· 0 Pentdlllns

0 SUlfa C) Latex (SUlfonamide AntibiotiCS)

Plea• describe ...,.,e drvg allergy ruction:

Pharmacy

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 Patient has no known drug allergies

0 Dairy products 0 mdeine sulfate 0 aspirin, bamen!d other:

Name:----------------------------------------------------------------------Current Medications 0 NOlle

Name Dose How taken?

Review Of Systems ~ ol ~ 0 1

Allarglcllmmunologlc z! Eyes >- z j 0 None l 0 None -§§ persistent infections ·~ light sensitivity . · · HIV exposu18 eye pain strong allergic reactions or urticaria

1 visual decline

u O' u ol

~~-- ---- -- -~ E ------ _,_ _zl chest pain belching irregular heart beat ' black stools s_hortness of breath .

1 bloating

u o change in bowel habitS Constitutional >- 2 I constipation C) None

1 dlarrbea

weight loss ; heartbumlref'wc

Hematologldl.ymphatic C) None easy bruising prolonged bleeding abnonnal blood clotting

Ill I

~ ~j I

§§ ~ o/

Integumentary ,.-- Z 1

0 None i E~ ----- -----sa

~ Musculoskeletal >- z i 0 None I =.a.-------- -~

u o' Neurological >- z I

=~-~~-- -·-·w: =-~ weight gain . mucous In stools

., oi nausea ENIIT >- z 1 painful stools

,QNone I

=heada~---------gg O N 1 rectal bleeding

g----- ---- ---~ ?-., g ;

Endocrine >- z i Genitourinary 0 None O None excessiVe tfiiFst · -- ·· - -C9ld intolerance heat intolerance

.§§ "' ~ ~;

Respiratoly ! 0 None : ==:·-- -- -----§§

6ii:i0ifm urine'" - ... -- ---. ----- ---­burning urination

loss of consciousness sa u oi

Psychiatric >- z! 0 None ~ iinxiety/pilnic·- -------­depression difficulty sleeping

-- - --§§

Procedure Scheduling Form

Patient:. _______________ _ DOB:. _____________ _

Your doctor referred you for a procedure because of what symptoms? ____ __

Please fill in all information listed below to assure your appointment is scheduled for your convenience and all major health issues are taken into consideration for safety of your preparation prior to the procedure.

YOU ARE SEDATED FOR THESE PROCEDURES AND WILL NEED SOMEONE TO DRIVE YOU HOME AFTERWARD.

Please choose from our physicians listed below to perform the procedure: Stuart Coleman David Dresner James Strobel __ __ Huey Nguyen__ Abdul Jab bar Steven Harrell __ Matthew McCollough Emori Bizer No preference __

Schedule procedure on: Monday Tuesday Wednesday Thursday Friday Any

Is there any specific date(s) good for you? ________________ _

Is there any specific date(s) NOT good for you? ______________ _

Are you allergic to latex? __yes _no Are you a diabetic? __yes no Ifyes, controlled by: diet

__ medicine -please list name and dosage __________ _ __ insulin- dosage __________________ _

Please list any medications for: Arthritis __yes _none Heart disease __yes _none Blood thinner __yes _none Date started: -------Do you have an artificial heart valve? __yes _no Date of surgery: _______ _ Type of valve: __ Mitral Aortic If yes, do you receive antibiotics prior to dental work or surgery? _yes no Do you have a pacemaker? _yes _no Date of placement:---------If yes, list brand and model. ___________________ _ Have you had stent placement during heart surgery? _yes _no Date of surgery: ____ _ Do you have a personal history of cancer? _______________ _

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

GASTROENTEROLOGY HEALTH PARTNERS, PLLC

d/b/a/ GASTROENTEROLOGY OF SOUTHERN INDIANA, PC

GASTROENTEROLOGY HEALTH PARTNERS, PLLC reserves the right to modify the privacy practices outlined in

the notice.

Signature

I have received a copy of the "Notice of Privacy Practices" for GASTROENTEROLOGY HEALTH PARTNERS, PLLC.

Name of Patient {Print or Type)

Signature of Patient

Date

Signature of Patient Representative (Required if the patient is a minor or an adult who is unable to sign this form)

Relationship of Patient Representative to Patient

This notice is effective on or after July 1, 2013.

STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Information to be Used or Disclosed

The information covered by this authorization includes:

Purposes of Disclosure

Information listed above will be disclosed for the following purposes:

Persons Authorized to Use or Disclose Information

Information listed above will be used or disclosed by:

Name of person/organization

Name of person/organization

Name of person/organization

Persons to Whom Information May Be Disclosed

Name of person/organization

Name of person/organization

Name of person/organization

Expiration Date of Authorization

This authorization is effective through__} _/20_ unless revoked or terminated earlier by the patient or

the patient's personal representative.

Right To Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to Gastroenterology Health

Partners, PLLC. You should contact the HIPAA Privacy Officer to terminate this authorization.

This notice is effective on or after July 1, 2013.

NOTICE OF PRIVACY PRACTICES

GASTROENTEROLOGY HEALTH PARTNERS, PLLC

d/b/a/ GASTROENTEROLOGY OF SOUTHERN INDIANA, PC

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for

the purpose of evaluating your health, diagnosing medical conditions and providing treatment. For example, results of

laboratory tests and procedures will be available in your medical record to all health professionals who may provide

treatment or who may be consulted by staff members.

Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage

such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your

health plan may request and receive information on dates of service, the services provided, and the medical condition

being treated.

Health care operations. Your health information may be used as necessary to support the day-to-day activities and

management of Gastroenterology Health Partners. For example, information on the services you received may be used

to support budgeting and financial reporting, and activities to evaluat~ and promote quality.

Law Enforcement. Your health information may be discussed to law enforcement agencies to support government

audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated

reporting.

Public health reporting. Your health information may be disclosed to public health agencies as required by law. For

example, we are required to report certain communicable diseases to the state's public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose

other than those listed above requires your specific written authorization. If you change your mind after authorizing a

use or disclosure of your information you may submit a written revocation of the authorization. However, your decision

to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified

us of your decision to revoke your authorization.

Additional Uses of Information

Appointment reminders. Your health information will be used by our staff to send you appointment reminders.

Information about treatments. Your health information may be used to send you information that you may find

interesting on the treatment and management of your medical condition. We may also send you information describing

other health-related products and services that we believe may interest you.

This notice is effective on or after July 1, 2013.

Fundraising. Unless you request us not to, we will use your name and address to support our fundraising efforts. If you

do not want to participate in fund raising efforts, please check off the following box.

o Please do not use my information for fundraising purposes.

Individual Rights

You have certain rights under the federal privacy standards. These include:

• The right to request restrictions on the use and disclosure of your protected health information

• The right to receive confidential communications concerning your medical condition and treatment

• The right to inspect and copy your protected health information

• The right to amend or submit corrections to your protected health information

• The right to receive an accounting of how and to whom your protected health information has been disclosed

• The right to receive a printed copy of this notice

Gastroenterology Health Partners. PLLC Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this

"Notice of Privacy Practices".

We also are required by abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our

policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will

provide you with the most recently revised notice on any office visit. These revised policies and practices will be applied

to all protected health information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted by federal

regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may

obtain a form to request access to your records by contacting our Office Manager, Sammye Wright, or Laurie Streib, our

HIPAA Privacy Officer. Your request will be reviewed and will be generally approved unless there are legal or medical

reasons to deny the request.

Complaints and Contact Information

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter

outlining your concerns to:

Laurie Streib, HIPM Privacy Officer

Gastroenterology Health Partners, PLLC

2630 Grant Line Road

New Albany, IN 47150

This notice is effective on or after July 1, 2013.

GASTRO~NTEROLOGY OF SOUTHERN INDIA.NA, P.C.

PATIENT FINANCIAL POLICY

Thank you for choosing us as your health care prov!der. We are committed to providing you with the best possible care and to your treatment being succesSful. ·Your clear understanding of our financial policy is important to our professional relationship. Please understand that payment of your bill is considered part of your treatment. we accept Casti, Check, Money Order, Visa, Mastercard and Discover. · · ·

INSURANCE

Our practice is committed to providing the best treatment for our patients. We must emphasize that as Medical care provider~, our relationship is with you, our patient, not with your insurance company. We cannot accept the responsibility of negotiating the claims with insurance companies or any other persons. While the filing of insurance claims is a "courtesyn that we extend to our patients, all charges are your responsibility· from the date of the services rendered.

Your insurance coverage is a contract between you and your insurance company. It is very important that you understand the provisions. of your policy. We cannot guarantee payment of claims. If your Insurance company pays only a portion of the bill or rejects your claim, any contact or explanation shou·ld be made to you, their policyholder. Reduction or rejection of your claim by your insurance company does not relieve you of your financial obligation.

Not all services are a covered benefit In all contracts. Some insurance companies arbitrarily ·select certain services they will not cover. Some of the services may be considered ."non-coveredn services and not considered necessary under Medicare and other medical insurance programs. Please remember that prOfessional services are rendered and charged to the patient, not the insurance company.

We charge what is usual and customary for our area. The patient is responsible for payment in full within a reasonable time - regardless of the status of the claim or any insurance company's arbitrary determination of usual and customary rates. Our fees are considered to fall within the acceptable range of most companies and therefore are covered up to the maximum allowance determined by each carrier.

If you have a managed care medical Insurance that we participate with, your payment of deductibles, non-covered services and co-payments are due when services are rendered. If we do not participate with your insurance company or if you do not have health insurance coverage, payment in full for services is due at the time· services are rendered.

Although an insurance claim is filed, you will receive. a monthly statement if your account has a balance due. This office cannot accept responsibility for collecting your insurance claim or for negotiating a settlement on a disputed claim. The patient is responsible for payment.

If you would have a procedure by any one of our physicians at Southern Indiana Endoscopy, LLC, (SIE) our ambulatory surgical center, you will receive a bill from SIE for ·a facility fee and GSI for a physlcian's.fee and pathology, if any.

In the event that you ca.nnot pay your balance in full, we e,ncourage you to contact our financial department for assistance In the management of your account. If your account becomes delinquent and you have not responded to our collection efforts, your account may be turned over to an outside source for collecting the balance due,.and at which time you will be responsible for all fe~s related to that expense.· Failure to respond to collection efforts may result ·in your dismissal from our practice.

COMMUNICATIONS REGARDING MY ACCOUNTS

Until my accounts are finally settled, I give my direct consent to receive communications regarding my accounts from any servicers and any collectors of my accounts, through various means such as 1) any cell, landline or text number that I provide, 2) any email address that I provide, 3) auto dialer systems, 4) volcemail messages and other forms or communications.

RETURNED CHECKS

Any returned checks are subject to a $35.00 service fee. Any returned check must be resolved before any future appointments can be arranged.

Patient Financial Policy Page 2

MISSED/RESCHEDULED APPOINTMENT POLICY (Effective November 1, 2009)

We make every effort to strive for excellence in our specialty and in our profession. An important aspect of providing quality care is to be respectful of your time and make every attempt to accommodate your scheduling needs. To accomplish this, it is very important to be on time for your appointment, arriving early for paperwork, and to notify us In the event you need to reschedule this appointment. We reserve an ample amount of time for our patients because we feel it Is important In providing quality health care. Therefore, sufficient notice to change your appointment is necessary in order to accommodate your needs and to have the opportunity to offer this time to another patient.

Due to the increasing number of "no show" patients, we have made the difficult decision to assess a "no show" fee to patients who simply do not show for a previously scheduled appointment. We greatly appreciate your consideration in calling us at least 2 business days prior to your scheduled appointment for any cancellations or rescheduling needs. Appointments that are not cancel/edfrescheduled by 1.2:00 noon the day prior to your appointment will incur a $25.00 charge. It is our sincere hope that this will not be necessary.

Please Note: This charge is not covered or paid by any insurance company; therefore, the charge will be billed directly to the patient. This fee must be paid prior to being seen for any rescheduled appointments. To reschedule or cancel an appointment, please call our appointment line directly, (812) 206-7090. If the appointment scheduler Is with a patient, please feel free to leave a message on her voice mall. Your call will be promptly returned If necessary.

MINOR AGE PATIENTS

For unaccompanied minors, treatment will be denied unless charges have been pre-authorized prior to date of service. The adult accompanying a minor and the parents or guardians are responsible for payment In full.

MEDICARE, MEDICAID, PRIVATE INSURANCES

If you are covered by one of the above, or any other government sponsored program, you must present your current insurance card prior to services being rendered. If your card is not available, we will be happy to reschedule your appointment.

WORKMAN'S COMPENSATION, AUTOMOBILE ACCIDENTS

If you are covered by one of the above, we do not file on these services and payment in full is due at time of service, although we will provide you with any information that you may need to file for these services on your own.

FMLA/DISABILITY FORMS (Effective November 1, 2009)

Gastroenterology of Southern Indiana, P.C. will charge $35.00 for each FMLA and/or disability form we complete. These fees must be paid prior to the forms being complete.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.

1 have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice.

Patient or responsible party Date

Patient Name (Print) Date of Birth