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  • PATIENT DEMOGRAPHIC AND HISTORY

  • Mobile device: any selection should be accepted by pressing Done on your keypad.

    Please don't press Go /  Enter / Return on your keypad, as this will take you to the end of the form and will signal "Error". If this situation occurs, ignore the error message and return to filling out the form.

    Feel free to use Voice Recognition, but deactivate it or press Done before moving onto the next field.

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    PC/Mac: Don't press Enter  or Return while filling out the form, as this will take you to the end of the form and will signal "Error". If this situation occurs, ignore the error message and return to filling out the form.

  • PATIENT INFORMATION

  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Appointment Date (if given)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year

  • INSURANCE INFORMATION

  • Responsible Party
  • Date of Birth of Insured
     / /
    2 digit month, 2 digit day, 4 digit year
    • Secondary Insurance (click to open) 
    • Responsible Party
    • Date of Birth of Insured (secondary)
       / /
      2 digit month, 2 digit day, 4 digit year
    •  
    • Format: (000) 000-0000.
    • Can we discuss medical conditions with other members of your family household?*
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Patient's Race*
    • Patient's Ethnic Group*
    • Format: (000) 000-0000.
    • Would you like a chaperone during exam?

    • I authorize the release of medical information to my primary care or referring physician, to consultants if needed, and as necessary to process insurance claims, insurance applications, and prescriptions. I also authorize payment of medical benefits to the physician.

      In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in an insurance plan in which we participate. For those patients, applicable copayments will be collected. We accept payment in the form of credit card or cash. If we do accept a check for payment, and the check does not clear the bank, a $25.00 service fee will be automatically cashed to your account. Please note that any procedure performed in the office (including anoscopy) may be billed separately and in addition to the office visit fee.

      Your signature below signifies your understanding and willingness to comply with this policy.

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    • HEALTH HISTORY

    • Are you having any rectal bleeding?*
    • If yes, is the bleeding bright or dark?
    • If yes, is the blood mixed with the stool or not mixed with the stool?
    • Do you have any blood on the toilet paper?*
    • Do you have blood in the toilet water?*
    • Do you feel your rectum is falling out of your anus?*
    • If yes, does the rectum go back in spontaneously?
    • If yes, do you ever have to push the rectum back in manually?
    • If yes, have you ever been unable to push the rectum back in?
    • Do you have severe pain around the anus?*
    • Do you feel a ripping at the anus with bowel movements?*
    • Do you have itching/burning at the anus?*
    • Did you ever have anal warts?*
    • Do you have drainage from the anus?*
    • Are you incontinent to solid stool?*
    • Are you incontinent to liquid stool?*
    • Are you incontinent to gas?*
    • In mothers, did you have birthing trauma that required stitches?
    • Do you have abdominal pain or cramps?*
    • Has anyone in your family had colon cancer at age less than 50?*
    • Has anyone in your family had colon polyps?*
    • Has anyone in your family had more than 10 colon polyps?*
    • Do you need antibiotics prior to dental procedures?*
    • Past Medical History
    • Are you taking Aspirin?*
    • Are you allergic to latex?*
    • Are you allergic to IV dye?*
    • Are you taking Plavix?*
    • Are you allergic to peanuts?*
    • Are you allergic to shellfish?*

    • Social History:

    • Do you smoke?*
    • Do your drink alcohol?*
    • If yes, daily?

    • Family History (please specify which family member had any of the following conditions)

    • Review of Systems:

    • Eyes:

    • Have your eyes turned yellow?*
    • Have your eyes turned yellow?*

    • Head, ears, nose, throat and neck:

    • Do you have loose teeth?*
    • Any chronic sinus problems?*
    • Any frequent nose bleeds?*
    • Do you have sleep apnea?*

    • Cardiac:

    • Do your legs ever swell up?*
    • Do you have chest pain?*
    • Does your heart ever flutter?*
    • Do you ever get light-headed?*

    • Lungs:

    • Do you get short of breath?*
    • Do you have a chronic cough?*

    • Gastrointestinal:

    • Have you been nauseated recently?*
    • Have you been vomiting recently?*
    • Are you constipated?*
    • Have you been having diarrhea recently?*

    • Genitourinary:

    • Do you urinate often during the night?*
    • Do you get urinary infections?*
    • Do you have blood in the urine?*
    • Any pain/burning when you urinate?*

    • Neurologic:

    • Do you have headaches?*
    • Any recent slurring of your speech?*
    • Are you sensitive to light?*
    • Have you ever been temporarily blind?*

    • Integuments:

    • Any skin ulcers?*
    • Dry skin?*
    • Any breast pain or masses?*
    • Any unusual rashes?*

    • Psychiatric:

    • Feeling down?*
    • Hearing voices?*
    • Trouble concentrating?*

    • Endocrine:

    • Gaining weight?*
    • Losing weight (not intentional)?*

    • Hematologic:

    • Bleeding problems?*
    • Prior blood clots?*
    • Sickle cell disease?*

    • Musculoskeletal:

    • Difficulty walking?*
    • Do your joints hurt?*

    • Have you had any of the following tests? (If yes, give the approximate date)

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    • Office Policies

      1. It is the patient's responsibility to check if our office/physician is in the patient's insurance network.

      2. If you have HMO insurance you are responsible for your referrals. Referrals are only valid for 90 days from the issue date and are only active for as many visits as your primary doctor has approved.

      3. You are responsible for knowing the policies of your insurance, such as co-pay, coinsurance, deductible, pre-existing conditions, policy exclusions, effective date, termination, etc.

      4. Co-pays and self-pay procedures are due at the time of service, with no exceptions.

      5. Each scheduled appointment in our office is considered an office visit and will be charged to your insurance

      6. If a procedure is performed (including anoscopy), it is an additional charge to your insurance.

      7. If your account is referred to a collection agency, you will be responsible for all collection fees which is 30% of the unpaid balance and reasonable attorney fees of one-third (1/3) of the balance referred to the attorney.

      8. If you are scheduled for a procedure it is your responsibility to make an appointment with your primary doctor for medical clearance. You are responsible to obtain your bowel prep and start it as instructed.

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    • Privacy Policy Acknowledgement Form

    • The Notice of Privacy Practice for the office of LM PRASAD M.D.,S.C is available for your review at the front desk and on our website www.chicagocolorectal.com. Should you wish to receive your own copy to take with you please ask our receptionist. The Notice of Privacy Practices may change from time to time and you are welcome to request a revised copy at your next visit, call our office and request a copy, or mail a written request.

      Section 1 - Acknowledgement

    • Section 2- Notification and Emergency Designee

      I give permission to LM PRASAD M.D.S.C. and staff to perform the following duties in an effort to maintain continuity of care:

    • Confirm/revise my appointment times by calling my home, business, and any other designated phone number*
    • Leave message of NORMAL test results on my home answering machine or with a specified family member*

    • The office and personnel are authorized to contact the party listed below to discuss and handle my medical care in the event of an emergency or to receive message information on my appointment and test results:

    • Format: (000) 000-0000.

    • Section 3 - Patient Portal

      This is the newest feature of your Electronic Health Records. We are excited to introduce this technology in patient communications. The Portal is secure and HIPPA compliant to ensure the safety of your Personal Health Information. When you are "web-enabled" with LM PRASAD M.D.S.C. you will be able to do the following via the web:

      1. Update your address, phone numbers, email address, employer, pharmacy, and emergency information.

      2. Enter or update your medical, surgical, and hospitalization histories as well as your allergy information.

      3. Receive email reminders of existing appointments, confirmations of new appointments as well as notifications of new information posted to the web portal.

      4. View your current and previous patient statement.

      5. View your current and previous appointments.

      Once you will provide us with your email address, we will set up your web ID and password. You will then be ready to use this great method of communication!

    • Please provide me with Patient Portal Access*

    • I understand the information provided to me in the Privacy Notice and I have indicated my response to the questions in each section

    • Format: (000) 000-0000.
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    • Colonoscopy Surgical Coding Guidelines

      Screening Colonoscopy - Average Risk - Procedure Code G0105 only, Diagnosis Code V76.51 only

      A screening colonoscopy is performed for average-risk patients and is covered once every 10 years. A patient must meet the following criteria to be considered for a screening colonoscopy:

      • Adults 45 years or older
      • Patients are asymptomatic (no present signs or symptoms)
      • Patients have no personal history of polyps or colorectal cancer
      • The patient has not had a colonoscopy in the last 10 years

      NOTE: If you have a preventative policy under your insurance plan the above criteria will apply to your procedure.

      Colonoscopy - High Risk

      A colonoscopy may be recommended by your physician every 2-5 years for the following high-risk patients:

      • A personal history of colon polyps
      • A personal history of colorectal cancer
      • A personal history of inflammatory bowel disease, including Crohn's disease and ulcerative colits
      • Who have a close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp (a type of polyp that could become cancerous)
      • Who have a family history of familial adenomatous polyposis (this involves multiple adenomatous polyps, often in the hundreds, and carries a very high risk of colon cancer)
      • Who have a family history of hereditary nonpolyposis colorectal cancer (a type of colorectal cancer that runs in families and tends to cause cancer at a relatively young age - under 40 years)

      NOTE: A high-risk colonoscopy is typically covered under your preventative plan.

    • Diagnostic Colonoscopy

      A diagnostic colonoscopy may be recommended for the following signs and symptoms:

      • Blood in stool/hem positive stool
      • Rectal bleeding
      • Iron deficiency anemia of unknown cause, confirmed by laboratory findings• Change in bowel habits
      • Persistent abdominal pain

      NOTE: A diagnostic colonoscopy will apply to your deductible and co-insurance.

      Financial Responsibility

      Most insurance companies offer preventative services and you can contact your insurance company if you have any questions (procedure codes are typically 45378, 45383 or 45385). It is the patient’s responsibility to know and understand their coverage and benefits.

      Please be aware that if you have a personal history of colon polyps/colorectal cancer this is usually covered as a diagnostic colonoscopy and your deductible and co-insurance apply.

      LM Prasad MD SC, Colon and Rectal Surgery obtains prior authorization for services that require authorization, but we cannot guarantee how it will be covered.

      Colonoscopy will create claims from several sources: you will receive bills/EOBs (Explanation of Benefits) for the physician performing the procedure, the facility where it was performed, anesthesia and pathology, if applicable.

      It is the patient’s responsibility to notify our office of any insurance changes prior to your scheduled procedure or your claim may be denied, making you financially responsible for the entire balance. Please be advised that LM Prasad MD SC, Colon and Rectal Surgery is not responsible for paying your deductible or co-insurance, therefore we DO NOT offer a discount after we receive payment from your insurance company.

    • Advanced Beneficiary Notice: Endoscopic Clipping

      Occasionally, after polyp removal during colonoscopy, your physician may decide to place a clip to close the defect in your colon or to control the bleeding (CPT billing code 45382). The same procedure is sometimes done for tumor localization. If your insurance company refuses to cover this part of the procedure, you will be charged $200.

    • Type a question*
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