Patient Intake

Our Offices

Select one or more offices you plan to visit

8000 Wolf River Blvd., #200, Germantown, TN 38138

1310 Wolf Park Drive, Germantown, TN 38138

1324 Wolf Park Drive, Germantown, TN 38138

2999 Center Oak Way, Germantown, TN 38138

3350 N Germantown Road, Bartlett, TN 38133

7668 Airways Blvd., Building B, Southaven, MS 38671

1325 Eastmoreland, #435, Memphis, TN 38104

76 Capital Way Cove, #E, Atoka, TN 38004

Patient Information

First Name

Middle Initial

Last Name

Date of Birth

Gender Male Female

Social Security

Address

City

State

Zip Code

Home Phone

Work Phone

Mobile Phone

Email

Pharmacy

Pharmacy Address

Pharmacy Phone

Employer Name

Employer Address

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone

Insurance Information

Primary Insurance Company Name

Insurance Co. Address

Name of Policyholder

Date of Birth

ID or Soc Security #

Group #

Relationship to Patient

Policyholder's Address (If other than patient)

Policyholder's Employer (If other than patient)

Policyholder Employer's Address (If other than patient)

Phone #

Secondary Insurace Company Name

Insurance Company Address

Name of Policyholder

Date of Birth

ID or Soc Security #

Group #

Relationship to Patient

Policyholder's Address (If other than patient)

Policyholder's Employer (If other than patient)

Policyholder Employer's Address (If other than patient)

Phone #

Authorization to Release Medical Informaion

I hereby authorize the release of my medical records TO GASTRO ONE from ALL MEDICAL SOURCES so that my physician has the information he/she needs to provide medical care.

I only authorize the release of my medical records from TO GASTRO ONE

I hereby authorize the release of my medical records at GASTRO ONE to the following

Purpose of the disclosure is for medical care unless otherwise specified here

On what date will the authorization expire (Date or event may not exceed one year)?

This authorization applies to:

All medical records

Health care information only relating to the following treatment(s), condition (s) or dates of treatment (Specify Below)

Please Specify

Limited records to be released (examples lab work reports, imaging reports) (Specify Below)

Please Specify

If you DO NOT WANT certain portions of your medical records released, please specify or select below.

Not Authorized

Substance abuse

Psychological or psychiatric treatment

HIV/AIDS/STD

Appointment Request (Please check one)

SELF REQUESTED - You have asked to see a Gastro One physician or your physician has recommended one of the physicians at Gastro One.

PHYSICIAN REQUESTED

Name of the physician requesting an evaluation from a Gastro One physician.

Consent For Care

The physicians & staff of Gastro One &/ or the G.I. Diagnostic and Therapeutic Center, L.L.C. will be hereafter referred to as “Gastro One”. I hereby give my consent for treatment. My electronic signature indicates I have read and understand the information contained in this online form.

Emergency Care

In the event of a life threatening emergency, it is the policy of Gastro One to perform Cardiopulmonary Resuscitation (CPR) as necessary to stabilize our patients for transfer to an acute care health facility.

Do you have a living will Yes No

Are you an organ donor? Yes No

Communications Regarding Your Health Care Information

Please indicate with whom we may discuss your healthcare. Check all that apply.

I hereby authorize Gastro One to leave messages regarding pending appointments or tests at my residence.

Gastro One may communicate information regarding my healthcare with the individuals listed below:

Name

Relationship

Name

Relationship

Name

Relationship

Gastro One may not communicate my healthcare information with anyone other than me.

Please review the following information:

Financial Policy

We are committed to providing our patients with the best possible care. If you have medical insurance, we will do all that we can to help you receive your maximum allowable benefit. In order to achieve these goals, we need your assistance and your understanding of our payment policy. If you are enrolled in a managed care plan, you are responsible for informing Gastro One of any special requirements of your insurance plan. If lab work or other diagnostic tests are orderd and sent to an outside lab or other facility you will be billed directly by the outside lab or facility and payment is your responibility. We will file your insurance claim for you; however, we ask that you pay any co-payment or deductible at the time our services are rendered and the balance in full within 90 days regardless of insurance filing. We accept Cash, Check, American Express, Discover, MasterCard, or Visa. We realize temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If your account is turned over to a professional collection agency you will be dismissed from care by physicians employed by Gastro One &/or G.I. Diagnostic & Therapeutic Center, L.L.C.

If you have any questions about the above information, or any uncertainty regarding insurance coverage, please do not hesitate to ask. We are here to help you.

I have read and understand this explanation of the financial policy of Gastro One and hereby authorize the release of any medical information deemed necessary to process any insurance claim for services rendered. This form is authorization for all medical benefits from any insurance company on said claims to be paid directly to Gastro One &/or G.I. Diagnostic & Therapeutic Center, L.L.C.

Medicare Extended Payment Request

I request payment of authorized Medicare benefits to be made either to me or on my behalf to: the physicians of the Gastro One and/or G. I. Diagnostic & Therapeutic Center, L.L.C. for any services provided me. I authorize any holder of medical information about me, to release to the Center for Medicare and Medicaid Services and its agents, any information needed to determine these benefits or the benefits payable for related services.

Health Insurance Portability and Accountability Act

My electronic signature indicates I have received a copy of the “Notice of Privacy Practices” from Gastro One and I understand how my health care information will be used and /or disclosed.

Signature

Please use a mouse, stylus, or finger to sign the paperwork you just completed. This signature will be applied to all information entered:

Patient Information
Insurance Information
Medical Release Authorization
Consent for Care
Emergency Care
Communications Regarding Your Health Care

Please use the Previous button to review the forms you have completed and/or to make corrections before signing

Thank You!

Patient or Guardian Signature

Relationship to patient

Thank you!

We have recieved your completed online patient information forms. We look forward to seeing you soon!

Our Offices

Patient Information

Insurance Information

Authorization to Release Medical Informaion

This authorization applies to:

Appointment Request (Please check one)

Consent For Care

Emergency Care

Communications Regarding Your Health Care Information

Please review the following information:

Financial Policy

Medicare Extended Payment Request

Health Insurance Portability and Accountability Act

Signature

Thank you!

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