ASC Open Access Web Form

Dear Patient: Please complete this form to the best of your knowledge.

Open Access Colonoscopy is indicated for healthy patients who need a colonoscopy for colon cancer or surveillance of colon polyps. If you have active gastrointestinal symptoms please see your primary care physician who can refer you for immediate care. We will need to send a bowel prep prescription to your pharmacy, please indicate the pharmacy of your choice.

Please list ALL medications (including herbals, vitamins and over-the-counter)

**Anyone calling to discuss your Protected Health Information must be on this list and must be able to give us the Patient’s Date of Birth as indicated on this form.** Patient Full Name: Patients Date of Birth: Patient Chart Number:

INSURANCE AUTHORIZATION AND FINANCIAL AGREEMENT The Greenbrier Clinic Ambulatory Surgery Center currently participates with Medicare, Highmark Blue Cross/Blue Shield, Aetna, Cigna, Tricare and ACS Benefits. It is the patient’s responsibility to make sure that the initial referral to be seen in our office has been arranged through the primary care physician if required by insurance. *We will be glad to file any two insurances for you but you will be responsible for any fees not covered by your insurance plan.* IF YOU HAVE MEDICARE: I request that payment of authorized Medicare benefits be made to The Greenbrier Clinic Ambulatory Surgery Center for any services furnished by one of their Practitioners. I authorize any holder of medical information about me to release to the HealthCare Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. OTHER INSURANCES: I agree to be financially responsible for all fees. I authorize the release of any medical information necessary to process any insurance claim(s) and request payment be made directly to The Greenbrier Clinic Ambulatory Surgery Center. Collection Fee: I understand that if my account with The Greenbrier Clinic Ambulatory Surgery Center becomes delinquent and is placed in collections, a 25% collection fee will be added to the balance owed. No Show Fee: I understand that should I need to cancel or reschedule my appointment, this should be done no later than 10 days prior to the set appointment. Failure to do so may result in a $500 cancellation charge.

NOTE: If Medicare doesn’t pay for (D). Screening Colonoscopy below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the (D) Screening Colonoscopy below. Procedure: (D) Screening Colonoscopy Reason Medicare May not Pay: • Colonoscopy with no or low risk is only covered once every 10 years. • Colonoscopy with high risk is only covered once every 24 months. • Medicare does not guarantee payment until claim is received. Estimated Cost: (F) Colonoscopy no more than $1350 WHAT YOU NEED TO DO NOW: • Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you finish reading. • Choose an option below about whether to receive the (D) Screening Colonoscopy listed above. NOTE: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. Options (G): Check only one box. We cannot choose a box for you. (H) Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).

Signing below means that you have received and understand this notice.