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

    High Blood PressureStrokeHigh cholesterolGERD/Heartburn
    CHFAsthmaThyroid DiseaseCrohn’s/ ulcerative colitis
    Heart DiseaseSeizureDiabetesIBS (irritable bowel syndrome)
    EmphysemaDepressionArthritisHepatitis C


    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.
    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


    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.


    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


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




    Our office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations.  Protected health information is the information we create and obtain in providing our services to you.  Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment.  It also includes billing documents for those services.

    Examples of uses of your health information for treatment purposes are: A nurse obtains treatment information about you and records it in a health record.

    • During the course of your treatment, the physician determines he/she will need to consult with another specialist in the area.  He/she will share the information with such specialist and obtain his/her input.

    Example of use of your health information for paymentpurposes:  We submit requests for payment to your health insurance company.  The health insurance company or business associate helping us obtain payment, request information from us regarding your medical care given.  We will provide information to them about you and the care given.

    Example of use of your information for Health Care Operations:We may obtain services from business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance.  We will share information about you with such business associates as necessary to obtain these services.


    The health and billing records we maintain are the physical property of the doctor’s office.  You have the following rights with respect to your Protected Health information.

    1. Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office – we are not required to grant the request, but we will comply with any request granted;
    2. Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office.
    3. Right to inspect and copy your health record and billing record – you may exercise this right by delivering the request in writing to our office using the form we provide to you upon request; appeal a denial of access to your protected health information except in certain circumstances;
    4. Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request.  (The physician or other health care provider is not required to make such amendments); you may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
    1. Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request.  An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care
    2. Right to confidential communication by requesting that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we give you upon request; and,

    If you want to exercise any of the above rights, please contact the office manager of Mid-State Sports Medicine, 145 West Fourth St., Suite 300, Cookeville, TN, 38501, or call 931-525-6676 in person or in writing, during normal hours. S (he) will provide you with assistance on the steps to take to exercise your rights.


      The office is required to:

    1. Maintain the privacy of your health information as required by law;
    2. Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
    3. Abide by the terms of this Notice;
    4. Notify you if we cannot accommodate a requested restriction or request;
    5. Accommodate your reasonable requests regarding methods to communicate health information with you;
    6. Accommodate your request for an accounting of disclosures.

    We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.  If our information practices change, we will amend our Notice.  You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.

    To Request Information or File a Complaint

    If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the Office Manager of Mid-State Sports Medicine, 145 West Fourth St., Suite 300, Cookeville, TN, 38501 931-525-6676.

    Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to the Office Manager.  You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address and e-mail address are Office of Civil Rights, Washington, DC;

    • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office.
    • We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.  Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule.


    We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.  We may contact you as part of a fund raising effort.

    Notification – Opportunity to Agree or Object:  Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

    Communications with Family – Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.  We may use and disclose your protected health information to assist in disaster relief efforts.


    PUBLIC HEALTH ACTIVITIES Controlling Disease- As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

    Child Abuse & Neglect- We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.

    Food and Drug Administration (FDA) – We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

    Victims of Abuse, Neglect, or Domestic Violence- We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.

    Oversight Agencies- Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations; inspections; licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.

    Judicial/Administrative Proceedings – We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.

    Law Enforcement – We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting of certain types of wounds or the physical injury.

    Coroners, Medical Examiners and Funeral Directors – We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

    Organ Procurement Organizations – Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.

    Research – We may disclose information to researchers, when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.

    Threat to Health and Safety – To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

    For Specialized Governmental Functions – We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

    Other Uses and Disclosures – Other uses and disclosures besides those identified in the Notice will be made only as otherwise authorized by law or with your written authorization, which you may revoke except to the extent information or action has already been taken.