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What you need for your Initial Visit:
- Referral
- Co-pay
- Insurance card
- List of all meds currently
taking*
- Recent labs and test
results
Please Note: We have two(2)
locations.
All NEW patients will first be seen at Gastroenterology Consultants.
Call us with any questions.
Bring the following forms below:
PATIENT FINANCIAL OBLIGATION AGREEMENT
cancellation fee /missed appointments /insurance.
(requires patient signature at time of visit)
Word document- 15KB.
Adobe PDF form- 97KB.
Notice of
Privacy Practices - HIPAA.
(requires patient signature at time of
visit by using
the RECEIPT
document below*)
Adobe PDF form- 466KB.
Receipt for Notice of
Privacy Practices*
-above.
(requires patient signature at time of
visit)
Word document-
52KB.
Web page for fast printing/no download.
Adobe PDF form- 12KB.
NOTICE:
DISMISSAL POLICY:
Grounds for Dismissal from GCSJ and the purpose of the discharge
to get the best care for the patient going forward.
Adobe PDF form- 252KB.
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SELF PAY & PAYMENT
PLAN
AUTHORIZATION FORM
Colonoscopy - EGD - Flexible Sigmoidoscopy
BCEC Facility & GCSJ Physician
What you need
for All Surgical
Procedures:
Bring the following forms below:
Ambulatory Surgical
Patient Check List.
(requires patient to
fill-in required
information)
Word document- 59KB.
Web page for fast printing/no download.
Adobe PDF form-
111KB (fill w/typewriter).
CANCELLATION Acknowledgement.
(requires patient signature at time of
visit)
Adobe PDF form- 447KB.
Office & Hospital
Procedure List.
(requires patient/office to
fill-in required info)
Word document- 55KB.
Web page for fast printing/no download.
Adobe PDF form-
18KB.
Drugs to Hold before
All Procedures.
Go to: Patient Prep Instructions
for the downloadable
information.
Helpful
Information
Only:
Advance Directives / Living Will
Please see our Link section
for Free State-Specific forms to download and edit
from your own computer.
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