SingleMarriedDivorceWidowedSeparatedPartnered









    Race :

    American Indian/Alaskan NativeAsianAfrican AmericanNative Hawaiian/Other Pacific IslanderCaucasianOther RaceUnknownDeclined
    EthnicityHispanic or LatinoNon-Hispanic or LatinoDeclined


    Emergency Contact:







    Person responsible for the insurance policy (person who holds the insurance policy or legal guardian of a minor)



    List of current Medication or provide list of current medications:

    Chief Complaint: :

    Medical History (check all that applies)

    High Blood PressureStrokeHigh CholesteralGERD/HeartburnAsthmaHepatitis C
    CHFThyroid DiseaseCrohns/Ulcertative ColitisEmphysemaDespressionArthritis

    Allergies

    Past Surgical History (check all that applies)

    Heart CatheterizationGallbladder SurgeryOpen Heart SurgeryAppendix SxEGD / Stent
    PacemakerTonsil/adenoidsPeg tubeColon Resection


    Have you ever had a colonoscopy? Y or N if yes,

    Family History:

    Social History (circle):

    Have you ever smoke? Y or N Do you currently smoke? Y or N If yes

    Have you ever smoke? Y or N Do you currently smoke? Y or N If yes

    Have you ever had a colonoscopy? Y or N if yes,

    Authorization for Treatment/Release of Information



    1.Please list the Family member or significant others if any, whom we may inform about your medical condition.






    2. Can confidential Messages (Example: Appointment Reminders) be left on your telephone answering machine or voicemail.
    YesNo
    3. I have received a copy of HIPPA and Privacy Practice Forms.


    Patient/Guarantor Agreement:

    I understand that Bay area Gastroenterology Associates (BAGA is not the business of extending credit. Therefore, it is the policy of Bay area Gastroenterology Associates (BAGA) to require payment in full at the time of service. If unable to pay patient due balance in full at the time of service, I agree to make prior arrangements with the billing department.

    I understand that I am financially responsible for my/the patient’s account with Bay area Gastroenterology Associates (BAGA), regardless of my insurance benefits. I authorize a copy of this form to be valid as the original.



    Cancellation Policy:

    If you need to cancel or reschedule your appointment or procedure, we kindly ask that you give us a 24 hour notice so we have time to schedule another patient.

    I understand the cancellation policy that Bay Area Gastroenterology Associates (BAGA) has in place for office and surgical appointments.

    Otherwise your account may be charged $25 – Office Visits & $100 – Surgery Procedures



    PATIENT PORTAL AUTHORIZATION FORM

    Our patient portal lets established patients communicate more easily with us. The portal is not intended for “Web Visits” or new problems. Instead, it will make regular communication more flexible. The portal is a voluntary option and is free of charge to all patients. The patient portal provides you with a much more seamless way to access your health information and contact our office.

    Through the portal, you can:

    • Request refills
    • Update your contact and insurance information
    • Check your medication list, medical history and your visits
    • Get your lab results quickly

    Privacy matters. We will never sell/trade/abuse your email address. The patient portal is protected just like all other interactions with our office. We also think it’s important for you to protect privacy on your end, and we recommend that you protect your user name and password to avoid misuse.

    We take security seriously, too. Computer networks do have real risks. We use appropriate technologies to protect your health information. We follow all security laws, including HIPAA and HITECH.

    Bedside manner is complicated via email. It’s easy to misread information or emotion. We’ll try to keep things brief and clear on the Portal. We really appreciate your help on that, too. If a message takes a long time to write, it’s probably something better done in person at an office visit.

    If we have troubles, abuse or ‘Spam’, we may need to change policies, suspend accounts, or even terminate the portal.,/p>

    You can access the portal day or night, but we don’t have a 24 hour presence on our end. As a safeguard, the portal should not be used for pressing issues. If you are experiencing an emergency or have an urgent medical need, you should call our office. If it’s after hours, we recommend that you go to Urgent Care, the emergency room or call 911.

    By signing below, I understand there are pros and cons to using the patient portal for communications with the clinic. I have had a chance to discuss my concerns with the office and have my questions answered.

    By signing below, I acknowledge that I would like a Patient Portal account and agree to the terms and conditions set forth above.




    ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

    The law requires that Bay Area Gastroenterology make every effort to inform you of your rights related to your personal health information. By Signing below I acknowledge that:

    • I have read or had explained to me Bay Area Gastroenterology associate’s Notice of Privacy Practice and agree to continue care with Bay Area Gastroenterology Associates under said terms.
    • I was given the opportunity to read Bay Area Gastroenterology associates Notice of Privacy practice and declined but wish to continue may care with Bay Area Gastroenterology Associates under said terms.
    • I have read or had explained to me Bay Area Gastroenterology Associates notice of Privacy practice and do not wish to continue my care with Bay Area Gastroenterology Associates.

    Otherwise your account may be charged $25 – Office Visits & $100 – Surgery Procedures

    I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.




    If you are signing as a personal representative of the patient, please indicate your relationship.