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SOUTHWEST GASTROENTEROLOGY ASSOCIA

80 LANDINGS DRIVE SUITE 205 WASHINGTON, PA 15301 PHONE (724) 941-3020

FAX (724) 426-7713

RICHARD PANICCO, D.O. MOHAN PHANSE, M.D. PH

RICHARD KENNEY, D.O. JENNIFER TODEN, M.D. ***********************************************************

Gastroenterology New Patient/ Updat Please bring completed form with you to your app

Patient's name: Date of Birth: Age

Referring Physician Primary Care Physici

Problem or Reason for your visit

TES

ILiP JOSON, M.D.

MAN HAL TANNOUS, M .D *********** ** *** **********

e Form ointment.

__ Today's Date : _ ___ _ an ____________ _

Past Medical History (which of the following conditions are you currently b eing treated or have been t rea ted

for in the past?) PLEASE CHECK THE BOX IN THE COLUMN TO THE LEFT OF T HE DIAGNOSES. '! .\,." ,I ' • . ' , Acid Reflux Hemorrhoids Arrhythmia An er:ni.a i .. "

Stomach Ulcers Anal Fissure Hypertension Bleedi ng Disorder Crohn 's Disease Hepatitis B History of Endocarditi s Blood Clots

Ulcerative Colitis Hepatitis C Emphysema/COPD/ Ast hma History of blood t ransfusion Irritable Bowel Syndrome Gallstones Diabetes Cancer(specif ic type)

Colon Cancer Liver Problems Stroke Other: Colon Polyps Pancreatitis Seizure Disorder Organ Transplants: _._

Diverticulitis Heart Attack Kidney Disease

Past Surgical History (include year surgery was performed) PLEASE CHECK T HE BOX IN THE COLUMN TO THE

LEFT OF THE SURGERIES

Colon Resection Hemorrhoidectomy Arti f icial heart valve

Small Bowel Resection/ surgery Gastric bypass Joint repl ac~fnenr ...

Appendectomy Pacemaker Hysterectomy Cholecystectomy(gall bladder surgery) Defibrillator Other:

Past GI Procedures and Tests Year & Where it was performed Results if known

Colonoscopy

Upper Endoscopy Sigmoidoscopy Abdomina l CT 't(4 r . I .

Abdominal Ultrasound Other

Allergies Are you allergic to any medication? Yes DNo 0 If yes please describe i ncluding react ion __ -"-_ _

Have you ever had a react ion to anesthetic? DYes 0 No. If yes plea

Are you allergic to Latex? DYes 0 No

se describe ----- -----

.L.", .i.:.,'_

Current Height ___ ft. ___ inches Current Weight ______ Ibs.

Medications (List all current prescription and non-prescription medication. Attach additional pages if necessary)

Medication Name Dosage Frequency/Day Medication Name Dosage Frequency/ Day

, ..

Your Pharmacy Name/ Address ___________________________ _ Telephone# _________________________________ ___

Social History Occupation ___________________________________ _

Tobacco: 0 Never smoked .! ! o

o Current Smoker: How many packs/day ___ for how many years __ _

Former Smoker: How many packs/day for how many years_ Year quit_--,-,,,-,

Alcohol : 0 None 0 Beer 0 Wine 0 Liquor How often (i.e . # drinks per day or week, please describe usage : ___________ _

Caffeine : # cups per day: _--;=-________ _ Recreational Drugs: 0 Yes 0 No. If yes, please usage :

Family History (Please include which family member and age of diagnosis if known)

Mother Father Siblings Grandparents others

Colon Cancer -- -

Colon Polyps ~. . ......

Ulcerative Colitis

Crohn 's Disease -. Celiac Disease

Other GI Cancer

Liver Disease

Breast Cancer ...

Ovarian Cancer

Other Cancer

Diabetes Mellitus

Heart Disease - - -

Other .1 ~f',

i ----1

Systems Review (Do you have or have you recently experienced any of the following?)

DIGESTIVE SYSTEM a Difficu lty in Swallowing

a Solids

aLiquids a Heartburn/ Esophageal Reflux a Regurgitation

a Nausea aVomiting a Indigestion a Early Satiety a Abdomin al Pain

aRight Upper Quad rant

a Right Lower Quadrant a Left Upper Quadrant

a Left Lower Quadrant a Bloating/ Belching / Gaseousness a Gastro intestina l Bleeding a Change of Bowel Habits a Constipation

How many bowe l movements per week? __ a Hard/lumpy Stool a Difficul t passage of stools (i.e. st raining

Excessively to defecate) Sensation of incomplete evacuation

a Diarrhea How many bowel movements da ily? __ _

a Loose stool a Blood in Stool a Black Stool

B Rectal Bleeding ( in stool, commode, toilet paper) Unintentional Weight Loss

a Hemorrhoids a Ana l/Rectal Pain a Feca l incontinence/soiling

a Jaundice

EARS, EYES, NOSE, MOUTH THROAT a Hearing Loss

a Ear Pain/ Ringing

a Eye Pain a Blurry Vi sion a Eye Redness

a Mouth Ulcers/Sores a Sore throat a Hoarseness

SKIN aRash

GENERAL a Weight loss (how much: _-Ibs.)

a Fever/ Chills

a Fatigue/ Weakness a Loss of Appet ite

RESPIRATORY a Shortness of breath a Wheezing a Cough

CARDIAC a Chest Pain

a Palpitation a Irregular heartbeat a Swelling in legs

GENITOURINARY a Are you pregnant? a Blood in Urine a Difficulty with urination a Frequency or painful urination

MUSCULOSKELETAL a Joint pai n/ swelling

a Back Pain a Prob lems Walking a Muscle weakness

a Muscle pain

NEUROLOGIC aNumbness/ tingling

a Weakness aDizziness aHeadache

a Seizure a Tremor

HEMATOLOGIC a Easy bruising/ bleeding

ENDOCRINE a Heat/ co ld intolerance a Excessive thirst

PSYCHIATRIC a Depression a Anxiety a Excessive stress

DEMOGRAPHICS

DATE OF BIRTH : AGE:

SOCIAL SECURITY NUMBER:

ADDRESS: HOME TELEPHONE #: Do we have permission to leave a message on a voice recorder? CJ YES CJ NO

ALTERNATE TELEPHONE #: OCCUPATION : EMPLOYER: MARITAL STATUS

CJ SINGLE CJMARRIED CJ WIDOWED NAME OF SPOUSE:

LIVING ARRANGEMENTS 1["'] ALONE ["'] SPOUSE/ SIGNIFICANT OTHER ["'] SUPERVISED LIVING

IN CASE OF EMERGENCY CONTACT - .- -_.

NAME: _. - --

RELATIONSHIP: - .- -. --- ----

PHONE: -

INSURANCE INFORMATION SUBSCRIBER NAME:

RELATIONSHIP TO PATIENT:

DATE OF BIRTH :

INSURANCE COMPANY:

IS THIS PATIENT COVERED BY ANY SECONDARY INSURANCE? DYES 0 NO

SECONDARY INSURANCE IF APPLICABLE SUBSCRIBER NAME: -RELATIONSHIP TO PATIENT:

DATE OF BIRTH : --_. --

INSURANCE COMPANY: - -

HIPPA --I GIVE MY PERMISSION FOR SOUTHWEST GASTROENTEROLOGY ASSOCIATES TO DISCUSS ANY INFORMATION PERTAINING TO ;

MY MEDICAL CARE OR CONDITION WITH THE FOLLOWING PEOPLE (FAMILY MEMBER, FRIEND ETC) LlSTEO BELOW '

1_ 2. ________________ _

3. ________________ _ 4 _________________ _ i -- , i

soUTtfWES't GASTROENTEROLOGY ASSOCIATES 80 lANDINGS DRNE SUITE 205 '

WASHINGTQN, PA 15301

, FINANCIAL POUCY , Tl'lank yOu for choosing us as your health care provider. We are committed to providing you with the highest quality healthcare. In order to provide this care, It IS essential that our office run as efficiently as possible. Proper payment of a bill Is an Important part of this process. ' , 'The fOaowIns'" • statement of our ftna~1 policy. W. uk'that you .... d aftd lip the poley prior to your appointment.

Generallnfonnatlon Your Insurarice pOlicy Ii a 'c;ontract between you and your Insurarice company. It Is essential that you understand yoUr benefits and obligations under that agreement. Some of the services provided may Oat be covered under your plan. Please call your Insurance Company~ ask' If Southwest Gastroenterology Associates Is a provider under your policy and If the procedure- requIred Is covered. As a courtesy, we. ftle your Insurance claims for offlce visits and procedures. When we file a claim on your behalf, It Is undel"StX?Od that they payme'nts will be as-slgned to SoUthwest Gastroel1terology AssocIates. We cannot bill your Insurance carrier correctly un*'. you provide current Insurance Information. If you have two Insurance po1lc1es, It Is Important to know which plan Is primary and,whlch Is a secondary pol~. COnfusion of this Issue can lead to long delays In payment.

MedIcare payment PoAcy , , , Southwest Gastroenterology Is a partlclpatlng-prOvtder under Medicare. lbls means Medicare will pay the doctor's office directly for 80% of tI'Ie Mitdlcare allowed charae, after the deduc:tlbfe has been met. The remaining 2~ will be subfnltted to the supplemental Insurance plan. We will subm~ all claims Medlca'Fe and to supplemental Policies; The deduc.1:lble and the remaining uncovered amount,~ yourftrianclal ~Sponslbnlty, '

'P.at Due Accounts a returned Chedcs , After we blH your Insuranee company, you will be responsible for the unpaid portion of their set fees. We will send you a bill. A balance due after 90 days or a portion of the balance due as agreed In prior payment arrangements, wlllreJult In transfer of the responsible party'ucOOunt to col)ectlon. You' will ~ responsible for the collection agencies fees. Your account will be charged $30.00 for each returned checlc. , , "

R8fernIs Some Insurance policies requl\"e a prescription mm a primary care physician, and a referral frofT',the Insurance company prior to seelnl a ,sp,edailst. Please check with your pr1mary physician whether an electronic or paper referral Is necessary. Some prtmary physicians require 2 weeks to gfant a merTal. If the referral Is granted have them fax that to our office at (724-;426-n~). ,It Is the' responsibility of the patient to obI;aln all appropriate, referrals prior to ~Ilvery Of service. If the appropriate referrals are not obtained at the time of service, the patient Will be personally responsible for all charges. These referrals often have an expiration date and limited' nUn'lber of visits sO please monitor the dates and visits. '

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c:o-pay;nents~ CoInsurance. Deduc:tlbles , Patients are responsible for paying co-payments (paymt!nts at time of S8!'VICe), co-Insurance &. deductlbles. Most Insurance companies Pay a percentage of theTr allowable fee, the coinsuranCe Is the remaining portlon of that fee. Each year your Insurance company requires you to 'pay a set amount out of pocIcet; Iri addition to your deductible. We will bill you for these charges and you are laplly 'responsible for them, '

Usual and CUstomary Rates " Our practice Is committed 'to providing the ~ treatment for our patients; our tharaes are what Is usual and customary for our area. Under'some Insurance plana, You may be responsible for payment of these charges of the Insurance company's rate

, schedule. ' '

Date: I~ __ , ' Signature of Patient or Responsible Party ,

Please print your name

Southwest Gastroenterology Associates, P.A. 80 Landings Drive Suite 205

Washington, PA 15301

CONSENT FOR RELEASE OF INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

I, ' (your name), hereby authort~e Southwest Gastroenterology' Associates to use andlor 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'operatlons. I understand that while thls,consent 'ls voluntary, If I refuse to sign this consent, Southwest Gastroenterology ASsoc. can refuse to treat me.

, ' .

I have been 'nformed thit Southwest Gastroenterology Associates has prepared a notice ("Notice") , which' more fully describes that us~s and disclosures that can be made of my IridMdually Identifiable , health Information for treat, 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 Southwest Gastroenterology Associates; In writing, but If t revoke my consent, such ~vocatlon will not affect any actions that So~hwest Gastroenterology Associates took before receiving my revOcation. '

I understand that Sout~west Gastroenteroiogy ASsoclites has r.eserved the right to change Its privacy practices and that I can obtain such changed notice upon request.

, , ,

I understand that I have ~he rlght,to request Southwest Gastroenterology Associates restricts how my Indlvldualldentiflable health Information Is used and or/disclosed to carry out ,tre~tment, payment or health operations. I understand that Southwest Gastroenterology Associates does not have to agree to such restrictions, but that once such restrictions are agreed to, Southwest Gastroenterology Associates mush adhere to such restrictions.

Sllnature of patient or patients representative (Form MUST be completed before signing.)

Printed name of patle.nt or patle'1t's representat~e

Date