Flu:______Pneumonia______Mammogram______

Patient Health Information

Patient Name:______DOB:______Today’s Date:__________

How did you hear about us/Referring physician:

______

Reason for Today’s visit: ______

Have you had any of the problems below in the past week?

General: / Fever Excessive Sweating
Chills Fatigue
Appetite change
ENT: / Sinus congestion Sore throat Headache
Nose bleeds Hearing loss Mouth sores
Trouble swallowing Dental problem Hoarseness
Respiratory: / Chest tightness Wheezing
Shortness of breath Cough
Cardiovascular: / Chest pain Leg swelling
Palpitations
Genitourinary: / Difficulty urinating Kidney stones Flank pain
Blood in urine Urinary incontinence
Dysuria (painful urination)
Musculoskeletal: / Joint pain Back pain Gait problems
Joint swelling Muscle swelling
Muscle weakness
Skin: / Color change Wound
Rash Itching
Neurologic: / Dizziness Headaches Light-headedness
Numbness Seizures Speech difficulty
Fainting Weakness Confusion
Hematologic:
(Blood) / Swollen lymph nodes Bleeds/bruises easily
Anemia
Behavioral/
Psychological: / Agitation Behavior problem Self injury
Decreased concentration Nervous/Anxious
Difficulty sleeping

Acknowledgement of Review of Notice of Privacy Practices

I understand the Health Insurance Portability and Accountability of 1996 (HIPAA), I have certain right to privacy regarding my protected health information. This information can and will be used to:

  • Conduct, plan and direct treatment
  • Obtain payment from third party payers
  • Conduct normal healthcare operations such as quality assurance

I have had the opportunity to read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I also understand Houston Gastro Institute has the right to amend this notice and that I am entitled to an update copy of this notice if requested.

I understand that I may request in writing that you restrict how my health information is used or disclosed to carry out treatment and healthcare operations. However, I understand that the facility may not accept these requested restrictions, but if accepted must abide by treatment.

I understand that I have the right to review and copy my health information and request a change to any information that I believe is not complete list of each disclosure of my protected health information.

Person Authorized to Receive Health Information:

Patient Only

Other:

Name:______

Contact information:______

Ok to leave a message at home phone: ___ Yes ____ No, If yes, preferred phone #:______

Ok to email me: ___ Yes ___ No, If yes, Email address:______

I may revoke or terminate this authorization at anytime by submitting a written request to Houston Gastro Institute, pLLC., Attn: Privacy Officer.

______

Signature Date

Financial Policy Form

All patients must read and sign this form prior to receiving services.

It is your responsibility to provide us with your most current insurance information. If you fail to provide accurate insurance information in a timely manner, your insurance company may deny the claim.

If the claim has been denied, you will be financially responsible for the services rendered. We must emphasize that, as medical providers, our relationship is with you, the patient, and not your insurance company. Your insurance is a contact between you, your insurance and possibly your employer. It is your responsibility to know and understand the level of services covered by your insurance company.

We may accept assignment of insurance after verification of your coverage. Please be aware that some or perhaps all of these services provided may not be covered in full by your insurance company. It is your responsibility to provide us with your most current billing information.

Payment in full due upon time of service.

Houston Gastro Institute, pLLC will bill for the professional component of the fees (Physician Fee) for procedures performed outside of the office. Note that additional fees may apply under the following circumstances:

i)Pathology Fees- if biopsies are taken

ii)Anesthesia Fees- if general anesthesia is administered

iii)Hospital or Surgery Center Facility Fees

CANCELLATION POLICY

In an effort to best serve our patients; for office visits we may charge a fee of $25.00 for the cancellation/failure to keep an appointment. Please make every effort to notify this office within 24-48 hours of your office visit or scheduled procedure if you must cancel or reschedule.

I have read and understand the financial policy of this medical office and agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice without prior or written notice.

______

Signature Date

AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

Patient’s Name: ______

Date of Birth:______

I request and authorize the following practice:

Name of Clinic: ______

Phone Number: ______

Fax Number: ______

To release the medical records of the patient named above to:

Houston Gastro Institute

Dr. Vivian Asamoah, MD

777 S Fry Rd, Suite 206

Katy, TX 77450

This request and authorization applies to the release of:

□All Records / □Consult
Notes / □ Discharge
Summary / □ER Records / □ Colonoscopy
Report / □ EGD Report
□Pathology
Results / □ Labs / □ Ultrasound
Results / □ CT Results / □ MRI Results / □Pill Cam/ ERCP
□ Other:
Note to office:

I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/ or treatment for HIV (AIDS VIRUS), sexually transmitted diseases, psychiatric disorders/ mental health, or drugs and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing or treatment.

______

Signature of Patient or Patient’s Authorized Representative Date

Relationship or status if signed by anyone other than the patient: ______