Catawba Gastroenterology PA



Catawba Gastroenterology PA

108 Healthcare Dr 1380 Ebenezer Rd St E

Lancaster SC 29720 Rock Hill SC 29732

9963. 803-283-6330

Open Access Screening

The Open Access Colonoscopy Program makes this important screening procedure more accessible to everyone. The program allows healthy patients without significant symptoms to have a colonoscopy without the inconvenience of a preliminary office visit. It is considered to be a safe and appropriate for the right patients and there are many groups across the country with similar programs.

Please complete the medical questionnaire and send it to us. The questionnaire will be reviewed in our office to ensure that you do not need a preliminary office visit. You will be contacted and set up for either a colonoscopy or an office visit. Participation in the Open Access Program is contingent upon pre-procedure insurance approval.

Colon Cancer Screening

“Screening” is a test for the early diagnosis of common cancers before symptoms develop. Colon cancer is now the second leading cause of cancer deaths in the US and is equal in both men and women. The current recommendation for colon cancer screening by the American Cancer Society is a colonoscopy at age 50 (45 for African Americans due higher risk at earlier age). Future exams are planned on the findings and family history of colon cancer. If a screening colonoscopy is normal the next exam would be recommended in 10 years unless there is a family history of colon cancer or new symptoms.

Colonoscopy?

A colonoscopy is the procedure recommended by the American Cancer Society for colon cancer screening.

The day before the exam , you will follow a clear liquid diet: otherwise the days activities are unrestricted. That evening you will take medication to induce diarrhea to cleanse the colon for the next day’s exam. At midnight you will stop drinking liquids until after the procedure.

The next morning you will report to the designated facility where an IV is started and you are sedated in a monitored setting for the procedure. The procedure is passage of a flexible thin tube with a camera on the tip through the large intestine or colon for inspection and removal or biopsy of polyps or abnormal growths. Following the exam and a short recovery period you are discharged home with your escort and are instructed to relax the rest of the day.

The next day, typically there are no restrictions and you may return to normal activities.

Catawba Gastroenterology PA

108 Healthcare Dr 1380 Ebenezer Rd St E

Lancaster SC 29720 Rock Hill SC 29732

9964. 803-283-6330

Open Access Screening Questionnaire

Name_________________________________________________________________

Date of Birth__________________________Social Security Number______________

Address________________________________________________________________

City____________________________State__________________Zip______________

Telephone (Daytime)__________________________ Mobile_____________________

Primary Care Doctor ____________________Referring Doctor___________________

Insurance Carrier______________________Insured Name_______________________

Policy #_________________Group #_______________Insured SS#_______________

Relationship to Insured__________________ Insured Date of Birth________________

Insurance Customer Service Phone Number ___________________________________

**Please include copy of insurance card, front and back with completed paperwork**

List all active medical problems_____________________________________________

_______________________________________________________________________

List all medication (include over the counter products)___________________________

_______________________________________________________________________

Allergies to medications___________________________________________________

Please answer the following medical history questions by circling Yes or No.

Heart Disease

Yes No Coronary Artery Disease / Angina / Heart Attack

Yes No Congestive Heart Failure

Yes No Valvular Heart Disease

Lung Disease

Yes No Emphysema, COPD, Asthma, Bronchitis requiring regular medical therapy

Yes No Sleep Apnea

General Health

Yes No Kidney Failure

Yes No Stroke

Yes No Diabetes

Yes No Do you take antibiotics before dental work?

Yes No Have you had joint replacement within the last year?

Yes No Have you ever had a complication with anesthesia?

Gastroenterology

Yes No Do you heartburn more than twice a week?

Yes No Do you see blood in your bowel movements?

Yes No Do you have frequent constipation or diarrhea?

Yes No Do you have relatives with colon cancer? Who?_______________________________

Yes No Do you have a personal history of colon cancer? When?________________________

Release of Medical Records:

I authorize Catawba Gastroenterology to release my health information to the following entities: Insurance Companies, Disability Companies, Referring Physicians, and any Doctor Catawba Gastroenterology refers me to. ________________________

Patient Signature

I authorize _____________________________________(referring Doctor)to release any medical information needed for treatment. ______________________

Patient Signature

Financial Disclosures:

I agree to pay for any and all charges deemed as “patient responsibility” by my insurance company. All co-pays, deductibles, co-insurances, and deposits for procedures are due at the time of service. If uninsured, I understand I must make payment arrangements with a member of the office staff. ___________________

Patient Signature

Please return the completed form to our office. If there are no contradictions you will be assigned one of our physicians to be set-up for a colonoscopy. You may need a preliminary consultation if there are medical concerns identified that would need attention before scheduling your colonoscopy. Your insurance company will be notified for benefit verification. If you have not heard from our office within 10 days please call our office (803)-286-9963 and ask to speak to the Open Access Cordinator.

Mail Completed Form to: Catawba Gastroenterology PA, 108 Healthcare Dr, Lancaster SC 29720

Fax Completed Form to: Catawba Gastroenterology PA , 803-283-6330 Attn: Billing Manager

Email Completed Form to: catawbagastroenterology@ Subject line : Open Access

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