PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Address:

NEW HAMPSHIRE GASTROENTEROLOGY, INC. ** Please return this form completed ASAP**

9 Washington Place, Suite 204, Bedford, NH 03110 Office: 603-625-5744 Fax: 603-606-3049

PATIENT INFORMATION

Name: DOB: _____ ____ DATE:

Home Address:

Mailing Address if different:

City: State: Zip:

Phone: Cell Phone: _ Work phone: _______

Referring Physician: Primary Physician:

Email Address: ______________________________________________________________________

Parent/Guardian Name:

INSURANCE INFORMATION-

(INCLUDE A COPY OF FRONT & BACK OF CARD(S)

MEDICARE INSURANCE - PLEASE CIRCLE IF YOU HAVE PART A ONLY(HOSPITAL) OR PART A & B (HOSPITAL & DOCTOR)

Primary Insurance: ID #:

Insurance Address:

Policy Holder (if other than patient): DOB:

Relationship:

Secondary Insurance: ID #:

Insurance Address:

Policy Holder (if other than patient): DOB:

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I hereby authorize payment of medical benefits billed to my insurance to: NH GASTROENTEROLOGY, INC. for services rendered to me.

I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I also accept responsibility for services provided in the event that my Health insurance coverage is not in effect at the time of service, the procedure is not a covered benefit under my insurance plan and I have not obtained the appropriate referral required by my health insurance plan and the coverage is denied or reduced as a result.

I agree to pay all copayments at the time the service is rendered. I agree to pay all coinsurances and deductibles as required by my health care insurance.

I give my permission to NH Gastroenterology, Inc. to speak to the following person(s) in regard to my medical information:

DATE:

Signature of patient or guardian

New Hampshire Gastroenterology, Inc. ∙ 9 Washington Place, Suite 204 ∙ Bedford, NH 03110 Tel: 603-625-5744 Fax: 603-606-3049

REVIEW OF SYSTEMS

***PLEASE RETURN THIS FORM COMPLETED ASAP***

Name:___________________________________ Date of birth:___________ Date completed:_____________

(Please complete BOTH sides of this form. Fill out and check areas related to past and present health status and CARDIOVASCULAR

__Chest pain

__High blood pressure __Murmur

__Pacemaker/AICD __Heart surgery __Irregular heart beat __Heart valve

__Heart attack

Comments:__________________________________

GASTROINTESTINAL __Change in bowel habit __Black stools

__Colitis

__Crohn’s Disease __Rectal bleeding __Irritable bowel __Colon polyps __Colon cancer __Diverticulosis __Constipation __Diarrhea __Weight loss __Ulcers

__Trouble swallowing __Heartburn

__Hiatus Hernia __Nausea __Vomiting

__Stomach cancer __Liver problems __Hepatitis __Pancreatitis __Jaundice

Comments:__________________________________

RESPIRATORY __Asthma __Emphysema __Bronchitis

__Shortness of breath __Wheezing

__Cough __Pneumonia __Tuberculosis __Lung cancer

Comments:__________________________________

NEUROLOGICAL __Seizures

__Epilepsy __Headaches __Strokes

Comments:__________________________________

ORTHOPEDIC __Arthritis

__Joint replacement __Pins, plates __Gout

__Bone cancer

Comments:__________________________________

EMOTIONAL __Anxiety

__Schizophrenia __Mental retardation __Depression

__Manic Depressive

Comments:__________________________________

OTHER MEDICAL PROBLEMS-

__Diabetes __Thyroid __Kidney disease __MRSA __Urinary incontinence __Anemia __Eye problems

New Hampshire Gastroenterology, Inc. ∙ 9 Washington Place, Suite 204 ∙ Bedford, NH 03110 Tel: 603-625-5744 Fax: 603-606-3049

MEDICAL HISTORY

Primary Care Physician (PCP):___________________________Referring Physician:_________________________

Medications – please list prescriptions and over the counter medications below or attach separate sheet:

____________________________________________________________________________________________

____________________________________________________________________________________________

Do you take a blood thinners such as COUMADIN/WARFARIN/PLAVIX?___________________________________

Do you have any allergies? __Yes __No If Yes, please list _____________________________________________

Are you allergic to latex? __Yes __No Surgical tape? __Yes __No

Have you been hospitalized within the past year? __Yes __No If Yes, please list reason(s) why_______________

____________________________________________________________________________________________

List surgical procedures within the last 10 years _____________________________________________________

___________________________________________________________________________________________

Have you ever had a colonoscopy? __Yes __No If Yes, please list when and physician______________________

Have you ever had a sigmoidoscopy? __Yes __No If Yes, please list when and physician___________________

Have you ever had an upper endoscopy? __Yes __No If Yes, please list when and physician________________

___________________________________________________________________________________________

Do you have a family history of colon cancer? __Yes __No If Yes, who _________________________________

Do you have a family history of colon polyps? __Yes __No If Yes, who _________________________________

Why are you having this procedure done? _________________________________________________________

Have you been to this office or seen any of our physicians before? __Yes __No If Yes, who ________________

The following section must be completed:

I give permission to NH Gastroenterology, Inc. to release information to the following people (example spouse, son, daughter):___________________________________________________________________________________

I give permission to NH Gastroenterology, Inc to release information for treatment, payment and health care operations.

Patient signature ______________________________________ Date__________________________________

***PLEASE RETURN THIS FORM COMPLETEDTO OUR OFFICE AT LEAST 7 DAYS PRIOR TO YOUR PROCEDURE OR APPOINTMENT***

New Hampshire Gastroenterology, Inc

17 Riverside Street, Suite 203 • Nashua, NH 03062

Tel:(603)625-5744 ∙ Fax: (603)606-3049 ∙ Office Hours: M-TH 8:30am-5:00pm, F-8:00 am-4:30pm

Dear_____________________________________________,

You have been scheduled for a(n): EGD Colonoscopy Ablation ERCP Manometry Office Visit Enclosed is information pertaining to your procedure / appt on _____________________________

Check in time: ____________________________ (this time could change due to facility schedule) Your appointment is scheduled at:

* CMC- 100 McGregor St., Manchester, NH 03102

* BASC-

*

The Elliot @ the Rivers Edge-

* Office-

With Dr.Stuart Brogadir Dr.Mark Silversmith Dr. Christopher Dainiak Jessica Konopka, PA-C NOTE: There will be a $50.00 No Show or Late Cancellation Fee (less than 2 business days) for any office visit and

$100.00 No Show or Late Cancellation (less than 3 business days) for surgical procedures.

Please return to our Bedford office the completed forms as soon as you receive them with a copy of your insurance card, front and back.

Please follow your facility requirements listed below and bring a medication list with you on the day of your visit:

CMC: Check in at the front desk and they will direct you to the Endoscopy Suite.

BASC: Follow “Online Patient Registration” instructions at www.bedfordsurgical.com. Use Patient Code: BASC603ENDO Questions: BASC: 622-3670 or Cust. Service: 877-848-4726.*

RIVERS EDGE: Call at least one week prior to your appointment to pre-register @ 663-5663.

 Co-pays, deductibles and any co-insurance are the patient’s responsibility.

 Patient is responsible for obtaining a referral as needed per individual plan.

HIPAA – the privacy policy is available at your request

Bedford Ambulatory Surgical Center (BASC) patients – Disclosure of Ownership –Dr. Brogadir, Dr. Silversmith, and Dr. Dainiak maintain an ownership in this facility. You are not required to utilize this facility and may choose to have your procedure done

elsewhere. The office will provide an alternative referral upon your request.

N.H. GASTROENTEROLOGY

9 Washington Place, Suite 204

Bedford, N.H. 03110

CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT

AND HEALTH CARE OPERATIONS

I, ________________________________ , hereby authorize N.H. Gastroenterology to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and health care operations.

I understand that while this consent is voluntary, if I refuse to sign this consent, N.H. Gastroenterology can refuse to treat me.

I have been informed that N.H. Gastroenterology has prepared a notice ("Notice") which more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such Notice prior to signing this consent.

I understand that I may revoke this consent at any time by notifying N.H. Gastroenterology in writing, but if I revoke my consent, such revocation will not affect any actions that N.H. Gastroenterology took before receiving my revocation.

I understand that N.H. Gastroenterology has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request.

I understand that I have the right to request that N.H. Gastroenterology restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that N.H. Gastroenterology does not have to agree to such restrictions, but that once such restrictions are agreed to, N.H.

Gastroenterology must adhere to such restrictions.

Patient Name (please print)__________________________________________________

Patient Signature___________________________________________ Date __________

OR: Legal Representative, Parent or Legal Guardian

Signature___________________________________________________Date__________

Relationship to Patient______________________________________________________

Authorization to Obtain Medical History

By signing below, I hereby authorize NH Gastroenterology to obtain Medication History related to the patient above, from Community Pharmacies and /or Pharmacy Benefit Managers for the purpose of continued treatment.

Patient Signature______________________________________________Date___________

OR: Legal Representative, Parent, or Legal Gaurdian

Signature____________________________________________________Date___________