Gastroenterology Specialties, P.C. & Lincoln Endoscopy New Patient Registration Form

New Patient's Personal Information

Name*

First Last

Middle Initial

Marital Status*

Sex*

Race*

Ethnicity*

Language*

Address*

If apartment or suite, indicate in Address Line 2

Street Address Address Line 2 City State ZIP Code

Social Security Number #*

Date of Birth*

Home / Main Phone*

Work Phone

Cell Phone

Employer / School Name

Email

Spouse's Name (Enter NONE if Not Married)

Spouse's Employer

Spouse's Work Phone

Patient's Insurance Information

Primary Insurance Company's Name

Primary Insurance Company's Address

Street Address Address Line 2 City State ZIP Code

Primary Insured Information

Name of Insured	Date of Birth	Relationship to Insured

Primary Insurance ID #	Primary Group ID #

Secondary Insurance Company's Name

Secondary Insurance Company's Address

Street Address Address Line 2 City State ZIP Code

Secondary Insured Information

Name of Insured	Date of Birth	Relationship to Insured

Secondary Insurance ID #	Secondary Group ID #

Patient / Responsible Party Information

If the insurance is under the patients name this section can be left blank

Responsible Part (Name)

Date of Birth

Relationship to Patient

Social Security Number #

Home Phone

Work Phone

Address

If apartment or suite, indicate in Address Line 2

Street Address Address Line 2 City State ZIP Code

Employer's Name

Employer's Phone

Employer's Address

If apartment or suite, indicate in Address Line 2

Street Address Address Line 2 City State ZIP Code

Patient's Referal Information

Referred by Physician

Other Physician(s) Who Care for You

Emergency Contact Information

Name (of Person Not Living with You)

Relationship

Emergency Contact Address

Street Address City State ZIP Code

Emergency Home Phone

Emergency Work Phone

ASSIGNMENT OF BENEFITS • FINANCIAL AGREEMENT*

I hereby give authorization to release medical information necessary to process my health insurance claim and request payment of benefits be made to Gastroenterology Specialties, P.C. and/or the Lincoln Endoscopy Center, L.L.C. I understand I am financially responsible for charges not covered or denied by my insurance company. A photocopy of this agreement shall be as valid as the original. This authorization is to remain in effect until revoked in writing by me or my legal representation.

Patient's Signature or Responsible Party*

Today's Date*

Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, L.L.C.

Scheduling and Billing Policies

"No Show Policy"

Missed appointments without prior notification are considered "No Show" appointments. There will be a $25.00 fee assessed which will need to be paid in full prior to scheduling any further appointments. In the event of the first No Show, you will receive a letter of notification advising you of the No Show. The No Show will be documented in your account ledger and chart. In the event of Two No Shows or missed appointments, Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, LLC, will no longer provide patient care services either in the Clinic, Endoscopy Center, Hospital or Emergency Room setting. The patient will be advised of the discharge by a certified letter.

"Confirmations"

Please confirm your consultation appointment to avoid cancellation. You will receive a reminder telephone call from our office several days prior to your appointment in which we will advise you that you must confirm your appointment. Please call 465-4573 by 4:00 pm 3 days prior to the appointment or the appointment will be cancelled. If we do not receive medical records by 3:00 pm 2 days prior to the appointment, the appointment will be cancelled.

"Reschedules and Cancellations"

We track cancellations and reschedules. If you reschedule or cancel more than 3 times in one year you may not be allowed to reschedule a visit.

"Late Arrivals"

Late arrival for a scheduled appointment leads to inadequate time to accommodate the remaining patients on the schedule. As such, late arrivals of greater than 10 minutes may not be able to be seen depending on the time available. In addition, those patients who are on the schedule and here at the assigned time will be seen first. We will try to accommodate late appointments if time permits.

"Billing"

Gastroenterology Specialties and Lincoln Endoscopy Center require Deductibles, Coinsurance and Copays to be paid at the time of the visit. This will be collected at the reception desk at check in. Our office will check your insurance benefits and call you prior to your visit to discuss them with you. It is your responsibility to be aware of the limits of your insurance benefits. Once your insurance has paid, you will become responsible for any balance due. Payment is expected within 30 days of billing. If you are unable to make payment in full at the time of service, payment arrangements must be made prior to the visit. If requests for payments fail to settle an overdue balance, your account may be referred to a collection agency. If you do not have medical insurance and are self-pay, you will be expected to pay for the visit at the time of service.

"Repeat Exams, Tests and Procedures"

After a thorough initial work up by our physicians, it is sometimes necessary to repeat certain exams, tests, or procedures you might have already had done by your primary care or referring doctor.

Terms & Conditions*

I have read the Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, L.L.C. Scheduling and Billing Policies and I agree to the terms.

Only complete if you are a new patient with our practice.

New Patient's Personal Information

Patient's Insurance Information

Patient / Responsible Party Information

Patient's Referal Information

Emergency Contact Information

Gastroenterology Specialties, P.C. and Lincoln Endoscopy Center, L.L.C.

Scheduling and Billing Policies

"No Show Policy"

"Confirmations"

"Reschedules and Cancellations"

"Late Arrivals"

"Billing"

"Repeat Exams, Tests and Procedures"