PatientPop



Patient Name_______________________________________________________________________________________________________________ Phone Number(s): 1.) _________________________________________ Cell ___ Home ___ Other___ (please check one)

2.) _________________________________________ Cell ___ Home ___ Other ___ (please check one)

3.) __________________________________________ Cell ___ Home ___ Other ___ (please check one)

Address:______________________________________________________________City/State/Zip_______________________________________

Social Security Number:________________________________________DOB:___________________________________Sex: Male/Female

Race: (circle one) American Indian or Alaska Native / Asian / Native American / Black or African American / White / Hispanic / Other : __________________________________________________ / Refuse to Report

Are you self-pay? (circle one) Yes / No Do you have medical insurance coverage? (circle one) Yes / No

Primary Insurance ___________________________________ Secondary Insurance ______________________________________________

Family Doctor:_________________________________ Did this Dr. refer you: Y/N If not, what Dr. did?_________________________

Pharmacy:________________________________________________________City/State:___________________________________________________

I authorize Advanced Gastroenterology to access my prescription medication history and use this information as part of my medical chart. ________________________________YES ___________________________________NO

CONTINUE TO BACK SIDE

*Who to contact in case of emergency:_______________________________________Phone#_________________________________________

Relationship:_____________________________Can we give medical, billing, or prescription information to this person? Y/N

*Who to contact in case of emergency:_______________________________________Phone#_________________________________________

Relationship:_____________________________Can we give medical, billing, or prescription information to this person? Y/N

*Who to contact in case of emergency:_______________________________________Phone#_________________________________________

Relationship:____________________________ Can we give medical, billing, or prescription information to this person? Y/N

Can we leave normal test results on your voicemail? Y/N. If we are allowed to leave results on voicemail what number(s) should we call to leave the message?__________________________________________________________________

Request for Electronic Copy of Protected Health Information

Patient’s Name: ______________________________________ Date of Birth: __________________________________

I request that Advanced Gastro provide me with an electronic copy of my protected health information, through my Patient Portal. In order for this to be done I have provided my email below:

( Email Email Address: ___________________________________________________________

Please Print Clearly (If we cannot read your email address, we will not send your records.)

( DO NOT HAVE EMAIL

Through the Patient Portal, you will be able to

• ask questions

• request appointments, prescription refills and referrals

• update personal information

• review published lab results, statements, Personal Health Record [PHR]

… all from the comfort of your home, whenever it is convenient for you!

Signature of Patient: ___ Date: _____

Name of Personal Representative (if applicable): ____________

Signature of Personal Representative: Date: _____

Relationship to Patient: _______

CONTINUE TO BACK SIDE

Authorization to Release Medical Records/Information

Physician/Facility to provide records: _________________________________________________________

Patient Name: _________________________________________________________

Patient Address: _________________________________________________________

_________________________________________________________

Patient SSN: _______________________ Date of Birth: __________________________________________

Please Submit Records To: Kofi W. Nuako, MD

1109 E. Reelfoot Ave., Suite B

Union City, TN 38261

FAX: (731) 885-3692 OR (731) 885 -6171

RELEASE THESE RECORDS: Initials

1. All medical records at this facility

2. Only some portions of records maintained at facility (specify below)

I authorize Advanced Gastroenterology / Summit Endoscopy center to obtain the above said medical records from your facility.

______________________________________________ ___________________________

Patient Signature Date

**THIS REQUEST IS VALID FOR 1 YEAR FROM THE DATE SIGNED.

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PATIENT INFORMATION FORM

PLEASE FILL OUT THIS QUESTIONNAIRE COMPLETELY

Do you have a living will/advanced directive? YES / NO

Would you like more information? YES / NO

I agree and authorize treatment as deemed necessary by Advanced Gastroenterology and/or Summit Endoscopy Center. I hereby assign all medical/surgical benefits to which I am entitled to Advanced Gastroenterology and/or Summit Endoscopy Center. If I hold Medicare and/or Medigap insurance, I request payments be made on my behalf to Advanced Gastroenterology and/or Summit Endoscopy Center for any services furnished to me. This assignment will remain in effect until revoked by me in writing. A photocopy of this is considered as valid as an original. I understand that I am financially responsible for all allowed charges and co-payments that are not paid by my insurance company. I hereby authorize said assignee to release all information necessary for determination of benefits of my insurer or healthcare financing administration. In the event that I am denied coverage for any reason I will make arrangements to pay any bills within 90 days unless other financial arrangements have been made with the billing office, practice manager or physician. I further authorize the billing department to move any credit balances I may have, from entity to entity, in order to cover any outstanding balances. I authorize Advanced Gastroenterology and/or Summit Endoscopy Center to furnish my insurance company, physicians, or my attorney any information and/or opinions which they request or a photocopy of the same.

I have been offered and/or received a copy of the notice of privacy policy. I understand that the notice may change from time to time and I may request a copy at any time.

Patient or Responsible Party Signature: _____________________________________________ Date: __________________

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1109 E Reelfoot Ave., Suites B-C

Union City, TN 38261

Ph: (731) 884-0600

Fax: (731) 885-3692

Kofi Nuako, MD

Gastroenterologist

Laura Russell, CRNP

Family Nurse Practitioner

Amy Myers, CFNP

Family Nurse Practitioner

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