Gastroenterology Clinic Patient History Form
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3Gastroenterology Clinic, Inc.
611 Grammont Street • Monroe, LA 71201
(318) 325-2634
PATIENT ACCT. NO.
TRACKING NO.
TODAY'S DATE
PHYSICIAN
PATIENT NAME
HOME PHONE NO.
PATIENT ADDRESS
CITY
ST
ZIP CODE
DATE OF BIRTH
MARITAL STATUS
SEX
SOCIAL SECURITY #
REFERRING PHYSICIAN
IN CASE OF EMERGENCY CALL (OTHER THAN SPOUSE)
EMERGENCY CONTACT PHONE #
PATIENT'S EMPLOYER
BUSINESS PHONE NO.
SPOUSE'S NAME
SPOUSE'S EMPLOYER
SPOUSE'S WORK PHONE NO.
SPOUSE'S SOCIAL SECURITY #
SPOUSE'S DATE OF BIRTH
PRIMARY INSURANCE CARRIER
POLICY NO.
GROUP NO.
POLICY HOLDER
DATE OF BIRTH
GROUP NAME
SECONDARY INSURANCE CARRIER
POLICY NO.
GROUP NO.
POLICY HOLDER
DATE OF BIRTH
GROUP NAME
AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN
MEDICARE AUTHORIZATION
I hereby authorize payment of surgical and/or medical benefits to Gastroenterology Clinic, Inc. and further convey, transfer and
I certify that the information given by me in applying for a payment under Title XVII of the Social Security Act is correct.
assign all of my rights in my insurance coverage to Gastroenterology Clinic, Inc., for service rendered. I also hereby assign and transfer
I authorize any holder of medical or other information about me to release to the Social Security Administration or its
any and all rights, title, and interest to any claim for penalties and/or attorney fees arising under any state or federal law or regulation
intermediary or carriers any information needed for this or a related Medicare claim. I request that payment of autho-
related to the payment of any claim for benefits to Gastroenterology Clinic, Inc. Regardless of the extent of the insurance cov erage, I agree
rized benefits be made on my behalf once the physician has obtained the patient's one time authorization, he may sub -
to be responsible for the entire balance. I also authorize release of information pertaining to my claim to my insurance company and/or
mit any later Medicare claim on either an assigned or unassigned basis without obtaining any additional signature from
companies or my attorney. Once the physician has obtained the patient's one-time authorization, he may submit any later claim on either
the patient in submitting claims, he should indicate "Patient request for payment on file."
an assigned or unassigned basis without obtaining any additional signature from the patient. In submitting claims, he should indicate "Pa-
tient request for payment on file." I hereby authorize Gastroenterology Clinic to furnish information to any requesting physician.
X
X
Date:
Date:
GASTROENTEROLOGY CLINIC, INC.
ENDOSCOPY CENTER OF MONROE
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
I, (patient name)
, acknowledge receipt of the Notice of Privacy
Practices.
By
Date:
Signature of Patient or Representative
I, (provider)
, certify that I have made a good faith effort to
obtain written acknowledgment of the patient's receipt of the Notice of Privacy Practices, but the
acknowledgment was not obtained because:
By:
Date:
Signature of Provider
This document must be retained in the patient's chart for the longer of 6 years from the date of its creation or when it
was last in effect.
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