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Dear Patient,On behalf of all the staff, I welcome you to our office. We are pleased that you have selected us to care for yourhealthcare needs. We want you to know that we are committed to providing you with courteous, compassion andeducation you on your condition while respecting your privacy.During your first visit we will conduct a thorough examination. The exam will included a discussion of yourmedical history and the reason you are visiting us. Your doctor will then discuss his diagnosis and the suggestedtreatment with you. This visit is a consultation; a procedure will not be done on your first visit with us.Enclosed you will find a New Patient Packet, which includes the following documents,1. Patient Demographics Information2. A History and Physical Questionnaire3. Authorization to Release Information Form: to give permissions for telephone messages, work excuses, schoolexcuses, and an option for you to give specific permission to any family member or friend you wish to designate toparticipate in your healthcare with our office.4. Office Policies and Patient Responsibilities5. Notice of Privacy Practices6. Acknowledgement Form for the Notice of Privacy Practices7. Directions to our officePlease read and complete the packet in its entirety and bring it with you to your appointment. Also, do not forgetto bring your insurance card and picture id, and any medical records that pertain to the reason of your visit. On the day ofyour visit, please come prepared to pay a co-insurance, co-pay or deductible that may apply to this office visit. A preauthorization or referral may be required due to your insurance requirements. If possible, please arrive 15 minutes earlyso we can go over your information and any questions you may have.Should you any questions before your visit, please feel free call us. We look forward to seeing you on yourschedule appointment. If you cannot make the appointment that has been scheduled for you, please contact our office atleast 48 hours before your scheduled appointment time to reschedule or cancel.Sincerely,Siva K. Chockalingam, M.D.Enclosures
PATIENT INFORMATIONDate: Primary Care Doctor: Referring Doctor:Patient Name: Date of Birth: SSN Circle here if refuseAddress:City:State: Zip Code:Home No. Cell No. Work No.Can we E-mail you? If so what is your email address: @ .com or .net .milMarital Status: (please circle):MarriedRace: Circle One:African AmericanAsianWidowedDivorcedCaucasianNative Hawaiian or Other Pacific IslanderYour Employment Status: (please circle)SingleActiveSex (please circle):MaleFemaleHispanicAmerican Indian or Alaska NativeUnknownPatient declines to specifyRetiredDisabledUnemployedYour Employer: City:Work Phone No. Occupation:Are you in Hospice? YesNoEmergency Contact (Not currently living with you):Relationship to Patient: Phone:PRIMARY Insurance: Contract/I.D. Group No.:Policyholder Name: Relationship: Date of Birth:Social Security No. Employer:SECONDARY Insurance: Contract/I.D: Group No.:Policyholder Name: Relationship: Date of Birth:Social Security No. Employer:PERSON RESPONSIBLE FOR THE BILL:NameDate of Birth SSN:Address if different than patient:Relationship with patient:Pharmacy Name: City: Pharmacy Phone:
Authorization- CompoundThis authorization form permits: Associates In Gastroenterology, P.A. to use or disclose protected health informationlisted in the Description section below to the Entity or Person listed in the Receiving Entity section for the following patient:Name Birth DateReceiving Entity: Please check the boxes for thoseentities or persons you wish to get the describedinformation about you.Voice mail Home#Voice mail Business#Voice mail Cell phone#EmployerSchoolSpouse (Provide name)Telephone Number:Parent (Provide name)Telephone Number:Other (Please provide name)RelationshipTelephone Number:Description of information to be given to checkedEntity or Person. Appointment timeResults of lab test or x-raysOtherAppointment timeResults of lab test or x-raysOtherAppointment timeResults of lab test or x-raysOtherAppointment or absentee informationReturn to work or school information Family billing informationFinancial informationMedical information- please list Family billing informationFinancial informationMedical information- please list Financial information Medical information- please listPurpose - The purpose of this authorization is to meet the patient’s request for information disclosures and uses and toobtain the consent below.Consent for Patient Reminders and NotificationsYou are consenting to receive messages from us, your healthcare provider, Siva K. Chockalingam, M.D. that utilizes an automatic telephone dialing system to deliver atext, voice, or pre-recorded message that may contain health related information or healthcare management advice at the telephone number(s) that you haveprovided. You understand that you are not required to provide consent in order to receive such information or advice from your healthcare provider.Terms & ConditionsYour request to receive automated voice and text messages from us, your healthcare provider, constitutes your agreement to these terms and conditions. You agreethat we may send you automated voice and text messages through your wireless provider to the valid mobile or landline number that you have provided us. Youagree to indemnify, defend, and hold us, our technology service vendor – healow LLC, our electronic medical record vendor – eClinicalWorks LLC, and its affiliatedcompanies harmless from any third-party claims, liability, damages or costs arising from your request to receive automated voice or text messages or from providingus, your healthcare provider, with a phone number that is not your own. You agree that we and our technology solution vendors will not be liable for failed, delayed,or misdirected delivery of, any information sent to you or from you, including opt-out requests. You must be 18 years or older in order to participate or have theexpress permission of a parent/guardian (but in any case, you must be at least 13 years old). This is a standard-rate messaging program where message and datarates may apply. Frequency of messages may vary depending on the number of messages that you are due to be sent by your healthcare provider.Supported carriers include AT&T, Verizon Wireless, T-Mobile , Metro PCS , Sprint, Boost, Virgin Mobile, U.S. Cellular , and others. Additional carriers may be addedat any time. Carriers are not liable for delayed or undelivered messages. T-Mobile is not liable for delayed or undelivered messages.
Frequently asked questions:What sort of messages can we send you?As your healthcare provider, our goal is to stay in touch with you even when you’re not in their office. To keep the lines of communication open and based on need,we can send you messages via voice SMS/text, email and secure messages on the Patient Portal and using healow. Example of communication from our practice caninclude: appointment reminders, prescription refill messages and health/wellness notifications for tests or other procedures. We respect your need for privacy andwill not send you telemarketing related messages or share your contact details with anyone.What does it mean when you opt-in or activate?By choosing to opt-in for voice and or text messages from us, your healthcare provider office, you are consenting to receive phone, text and/or other electronicmessages to the number we have on file for you. We have chosen to use this automated service reminders offered by healow and eClinicalWorks. Please direct allyour communication directly with us, your healthcare provider office and not our technology vendor companies. Please note: Phone, emails and text messages areconsidered unsecure methods of contact and may result in disclosure of sensitive information to unauthorized individuals. You are assuming the risk involved byactivating these services and will not hold the practice responsible.Can you turn off these services later?Yes, simply contact us, your healthcare provider office and ask to adjust your communication preferences. You can also text STOP on reply to a text message that youreceive from us. On texting STOP, your phone number will be unsubscribed from this service and you will not receive any further health and wellness messagingnotifications via text.What if you need further help?Please note that these services are either simply to remind you of important or necessary steps that you need to take for living a better healthier lifestyle or foroffering you convenient ways to connect with us, your healthcare provider outside the walls of their clinic. If there is ever an emergency or if you need help, pleasecall 911 or call our offices during regular working hours right away. Should you need additional help text HELP on reply to a text message and access the samemessage.Did you know simple steps you take can protect your health information online?Password protect any device from which you view or download your health information, both on your mobile phone or home computer. Make sure your passwordmeets the criteria for a strong secure password which means it consists of a at least six characters and uses a combination of letters, numbers, and symbols. Also, ifyou are using a public computer to access your health information, be sure to log out.Talk or text you soon!Associates In Gastroenterology, P.A. with phone number 803-788-1100Berkeley Endoscopy Center, L.L.C. with phone number 803-788-1120Ether, L.L.C. with phone number 803-719-5253Expiration date or event: This authorization shall be enforce until revoked by the patient orVerification method or code: This practice will verify the identity of any entity requesting protected health information.Verification information may include: social security, date of birth, address, last appointment.Rights of the Patient - I understand that I have the right to refuse to sign this authorization and that my treatment willnot be conditioned on signing.I understand that I have the right to revoke this authorization at any time by sending a written notification to the addresslisted at the top of this form I understand that a revocation is not effective in cases where the information has alreadybeen used or disclosed but will be effective going forward.I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by therecipient and may no longer be protected by federal or state law.DateSignature of Patient or Personal Representative (as defined by HIPAA)
Welcome to Associates In Gastroenterology. This brochure is designed to provide you with helpful information about ourpolicies and procedures of operations. If you have questions regarding any of the policies below please contact our OfficeManager. The cost of care is expensive and a financial policy is a part of every medical practice.Patient Responsibilities and Financial PolicyPatients are ultimately responsible for all charges for services provided by Associates In Gastroenterology and payment isdue when services are rendered.If a procedure is scheduled, a non-refundable deposit may be required. This deposit will be applied to any deductible orco-pay that needs to be met.We have the right to deny any treatment that is determined a non-emergency by our physicians due to for any outstandingbalance.We accept payments by cash, personal check, debit card, VISA and MasterCard.Insured PatientsAs a courtesy, we will file your primary, secondary and tertiary insurance. If we participate with your insurancecompany, any amount due after the applicable contractual adjustment will be your responsibility.Please provide us with the most updated and current information necessary to file the claim. If this is not obtained on thedate of service rendered, you may be responsible for your bill. You are also responsible for notifying us of any changes ininsurance. A copy of your card is required at each visit. If you do not have your card at the time of the visit, you will beasked to sign a waiver and may be billed for the services.Please call your insurance company, if you need to verify that our office and physicians participate with them. Differentinsurance companies have different co-pays and deductibles. Please be aware of your individual policy requirements.You are required to pay your co-pay and/or deductible at the time of your visit with us.We do participate with Medicare and will file insurance that is secondary to Medicare. It is your responsibility to payyour co-insurance and/or deductible at the time of service.We are also a participating provider for SC Medicaid; however, you must have your current card at the time of service.Your card must have remaining visits left to be valid. Please verify with our office regarding our participation with anyHMO Medicaid Plan.It is the patient’s responsibility to provide us with the primary care physician referral form. Please check to see if yourinsurance requires a referral and verify that it is obtained before your visit. If a referral is required, but not obtained, fullpayment may be required from the patient at the time of service.Assignment of Benefits and Release of RecordAs a patient of our office, you agree to assign and authorize payment directly to Assoc
If a procedure is scheduled, a non-refundable deposit may be required. This deposit will be applied to any deductible or co-pay that needs to be met. We have the right to deny any treatment that is determined a non-emergency by our physicians due to for any outstanding balance.
