PLEASE COMPLETE ALL SECTIONS ON THIS FORM - TIGA

Joycelyn M. Theard, MD Obinna C. Ukabam, MDStormy O. Valdespino, FNP-C

PLEASE COMPLETE ALL SECTIONS ON THIS FORM

First Name: Initial: Last Name:

DOB: Gender: □ Male □ Female S.S. #:

Address:

City: State: Zip Code:

Home Phone #: Cell Phone #:

Work Phone #:

Ethnicity:

Email:

Marital Status: □ Single □ Married □ Divorced □ Widowed

Residential Status: □ Independent □ Nursing Home □ Assisted Living Facility:

Referring Provider: Phone:

Primary Care Provider: Phone:

EMERGENCY CONTACT

Name: Relationship:

Primary Number: Secondary Number:

INSURANCE INFORMATION

Primary Insurance: Policy: Group#:

Guarantor: DOB: SS#:

Secondary Insurance: Policy: Group#:

Guarantor: DOB: SS#:

AUTHORZATION & RELEASE

To the best of my knowledge, the questions on this form have been accurately and honestly answered. I understand that providing

incorrect information can be potentially dangerous to my health. It is MY RESPONSIBILITY to inform the doctor’s office of any

changes in my medical status. I authorize the healthcare staff to perform the necessary services I may need and release information

to other providers for my medical care.

Signature of Patient/Guardian Date

SOCIAL HISTORY

Children: □ Yes □ No If yes, number of children:

Alcohol use: □ Yes □ No If yes, How many/How often:

Tobacco use: □ Yes □ No If yes, How many/How often:

ALLERGIES

Check ALL that apply: □ Latex □ Penicillin □ Codeine □ Sulfa Drugs □ Iodine □ Aspirin □ NSAID

□ Other (if not listed):

□ Food Allergies:

□ No Known Drug/Food Allergies at this time.

HOSPITAL

Recent Hospitalization: □ Yes □ No If yes, Date/Location/Reason:

Was there any testing completed: □ Labs □ Radiology □ Other:

SURGICAL HISTORY

Cardio: □ Coronary artery bypass □ Coronary stent □ Defibrillator □ Heart valve replacement

□ Pacemaker (copy of card ID) □ Heart transplant □ Other (if not listed):

Gastrointestinal: □ Cholecystectomy □ Colon surgery □ Gastric (ulcer) Surgery

□ Fissure (fistula) repair □ Hemorrhoidectomy □ Gastric bypass □ Nissen fundoplication

□ Pancreatic surgery □ Appendectomy □ Splenectomy □ Hernia repair

□ Bowel resection

General: □ Nephrectomy □ Hysterectomy □ Salpingo-oophorectomy □ Tonsillectomy

□ Thyroidectomy □ Organ Transplant □ Repair of Fracture

Endoscopies: (if you are unable to remember the provider’s name, use the facility/location of procedure instead)

□ Colonoscopy Provider: Date:

□ Upper Endoscopy (EGD) Provider: Date:

□ Other: Provider: Date:

REVIEW OF SYMPTOMS

Gastrointestinal: □ {Abdominal Pain □ Black/Tarry Stool □ Blood in stool

□ Constipation □ Feeling of Fullness □ Gas/Bloating □ Heartburn

□ Hemorrhoid(s) □ Loss of Appetite □ Nausea □ Painful swallowing

□ Ulcer(s) □ Vomiting Blood

Genitourinary: □ Frequent Urination □ Painful Urination

Respiratory: □ Cough

□ Upper □ Lower}

□ Diarrhea

□ Vomiting

□ Kidney Failure/Dialysis □ Kidney Stone(s)

□ Shortness of breath on exertion □ Shortness of breath at rest

□ Wheezing


Personal History of CANCER: □ Breast □ Intestinal □ Ovarian □ Stomach □ Esophagus

□ Liver □ Pancreas □ Uterine □ Other:

Constitutional: □ Fatigue □ Fever □ Recent weight gain lbs.

□ Recent weight loss lbs.

Cardiovascular: □ Abnormal heart rhythm □ Chest Pain □ High-blood pressure □ Palpitations

Musculoskeletal: □ Arthritis □ Joint pain □ Rheumatoid arthritis

Dermatology: □ Rash □ Sores

HEENT: □ Hoarseness □ Sore throat

Neurological: □ Seizures □ Headaches

Psychiatric: □ Anxiety □ Dementia □ Depression

Family Medical History:

□ Cancer: □ Inflammatory Bowel Disease:

□ Auto-Immune Disorder: □ Colon Polyps:

□ Other:

PHARMACY:

Pharmacy: □ Local □ Mail Order Name:

Location: Phone #:

Include ALL prescription, over-the-counter, herbal vitamin, diet supplement(s), and other “occasional” medication.

Medication Name Frequency Reason Prescriber

RELEASE OF MEDICAL INFORMATION

In the event that I may be unable and/or unavailable to receive information relative to my medical condition(s), until further notice, I hereby authorize Texas Institute of Gastroenterology Associates, PA, to release and discuss medical information with the following parties:

Name of Individual Relationship Phone Number

Name of Individual Relationship Phone Number


I authorize Texas Institute of Gastroenterology Associates, PA, to view my prescription history from external sources: □ Yes □ No

May we call you at home: □ Yes □ No

May we call you at work: □ Yes □ No

May we call your cell phone: □ Yes □ No

May we leave a message with any household member? □ Yes □ No

May we leave a message on your voicemail/answering machine? □ Yes □ No

Signature of Patient/Guardian/Power of Attorney Printed Name Date


CONSENT AND UNDERSTANDING

This consent is required by the Health Insurance Portability and Accountability Act of 1996, HIPPA, to inform you of your rights for privacy and respect to your health information.

CONSENT RELATED TO PRIVACY NOTICE I have had a chance to review the Privacy Practice Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to request how my Protected Health Information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement.

CONSENT FOR CARE I, with my signature below, authorize (this practice), and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian of. This medical care may include services and supplies related to my health (or the identified person) and may include, but not limited to, preventative, diagnostic, therapeutic, rehabilitation, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the scale or dispensing of drugs, devices, equipment or other items required in accordance with a prescription. This consent includes contact and discussion with other healthcare professionals for care and treatment.

CONSENT FOR RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS I authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to this practice. I further consent to the use for any practice operational; needs as identified in the Privacy Practice Notice.

FINANCIAL POLICY We appreciate you choosing us for your healthcare needs. We will adhere to the following financial policy in order to consistently deliver high-quality care and services to you. The patient / responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the healthcare services received.

I UNDERSTAND that I am responsible for all co-payments, amounts applied to deductible, and other amounts that may bedeemed my responsibility by the payment sources, as required by my contract with my insurance plan and stateregulations.

I UNDERSTAND that if I have an insurance co-payment or co-insurance, I am expected to make payment at the time of myappointment service.

I UNDERSTAND that my contract with my insurance company may or may not cover some services. All insurance policies arenot the same. Texas Institute of Gastroenterology Associates, PA, is NOT responsible or able to know every policy available.It is my responsibility to verify applicable coverage prior to receiving the services. For example, not all health plans includescreenings as a benefit. If I seek care outside of the contract terms, I am aware that I may be responsible for all charges thatare incurred.

Thank you for your understanding and cooperation with this policy. It is our privilege to provide your medical care. I have read and understand the above listed consents and financial policy stated above and agree to accept full responsibility as described above.

Signature of Patient/Guardian/Power of Attorney Printed Name Date


AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patient Name: Date of Birth:

Social Security#:

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the

above patient.

RECORDS ARE NEEDED FOR:

□ Continuation of medical care □ Military □ Social Security/Disability □ Insurance

□ Personal use □ Other:

RECORDS TO BE RELEASED:

□ Consultation reports □ Emergency room records □ Lab report □ Pathology report

□ Operative reports □ Discharge/Death report □ Other

The above information may be released (specify name or title of the individual or the name of the organization to which records are to be released and the appropriate address):

TO: Doctor, Hospital, Attorney, Insurance Company, Self Phone Number

Address (street, city, State, Zip code) Fax Number

FROM: Doctor, Hospital, Attorney, Insurance Company, Self Phone Number

Address (street, city, State, Zip code) Fax Number

I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. I understand that the specified information to be released may be include but is not limited to history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, including HIV and/or AIDS.

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. This authorization will expire in 120 days from the date of my signature below, unless I revoke the authorization prior to that time. I understand and agree to pay a copying fee to cover the cost of the transfer.

Signature Patient/Legally Authorized Representative Date


PLEASE COMPLETE ALL SECTIONS ON THIS FORM - TIGA

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