Automated Patient Form - GastroCare LI

Step 1 of 3

**to be filled out in office**
PERMISSION FOR DISCLOSURE OF HEALTH INFORMATION

Verification of Family / Friend
Date

MM slash DD slash YYYY
Patient's Name
SS #
DOB
I give permission to GastroCare to discuss my private health information with the following people
TO DISCUSS MY PRIVATE HEALTH INFORMATION WITH
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Signature of Patient :
You have the right to change this disclosure of medical history at any time, as long as you notify this office in writing
**to be filled out in office**
AUTHORIZATION FOR USE OF SIGNATURE ON FILE ASSIGNMENT OF BENEFITS

The undersigned hereby assigns all monetary benefits to be received by me from any individual, insurance company, or other person or organization as a result of any medical treatment or related services rendered to me by GastroCare LI, partial or full payment directly to GastroCare LI of such benefits.

I also authorize the release of any medical or other information necessary to process claims, I authorize payment of medical benefits to GastroCare LI physicians or suppliersfor all services rendered to me using “SIGNATURE ON FILE”. I request that payment of authorized Medicare benefits be made either to me or on my behalf to GastroCare LI for services furnised to me by the provider
I authorize any holder of medical information about me to release to the Health Care Financing Admininistration and its agents any information needed to determine these benefits of the benefits payable for related services.

This agreement is applicable to all services rendered by GastroCare LI at any future date so long as I do not cancel this agreement in writing.

Due to the ever-changing coverage of insurance plans, in order to accommodate all our patients, we will continue to participate with many managed care plans. However, you
are responsible for knowing the benefits and exclusions of your plan. It will be your responsibility to provide us with complete and accurate insurance information. As always, we will file the claim, but any procedure not covered by
your plan will be your responsibility.

Thank you in advance for your anticipated cooperation in this matter
Date

MM slash DD slash YYYY
Patient name
Patient's Signature
Patient's Social Security Number

Step 1 of 3

PATIENT QUESTIONNAIRE

to be filled out in office

ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES

to be filled out in office

PERMISSION FOR DISCLOSURE OF HEALTH INFORMATION

TO DISCUSS MY PRIVATE HEALTH INFORMATION WITH

You have the right to change this disclosure of medical history at any time, as long as you notify this office in writing

to be filled out in office

AUTHORIZATION FOR USE OF SIGNATURE ON FILE ASSIGNMENT OF BENEFITS

GastroCare LI – Medical History Form

Family History

Social History

Inquiry

Valley Stream, NY

Glendale, NY

Connect with GastroCare LI

Directions

Valley Stream, NY

Directions

Glendale, NY

Directions

Step 1 of 3

PATIENT QUESTIONNAIRE

**to be filled out in office**

ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES

**to be filled out in office**

PERMISSION FOR DISCLOSURE OF HEALTH INFORMATION

TO DISCUSS MY PRIVATE HEALTH INFORMATION WITH

You have the right to change this disclosure of medical history at any time, as long as you notify this office in writing

**to be filled out in office**

AUTHORIZATION FOR USE OF SIGNATURE ON FILE ASSIGNMENT OF BENEFITS

GastroCare LI – Medical History Form

Family History

Social History

Inquiry

to be filled out in office

to be filled out in office

to be filled out in office