PATIENT DEMOGRAPHIC AND HISTORY

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.

---------------------------

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
Name*

First NameLast Name
Today's Date*

MonthDayYear
Appointment Date (if given)

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone
Ok to leave message:No
Work phone
Ok to leave message:No
Cell phone*
Ok to leave message:No
Date of Birth*

MonthDayYear
Social Security Number*
Marital Status*
Age*
Sex*
Email
example@example.com
Ok to leave results via emailNo
INSURANCE INFORMATION
Primary Insurance Co.
Responsible Party

SelfSpouseParent
Name of Insured
Address of Insured (if different)
Date of Birth of Insured

MonthDayYear
Employer Name
Relationship of patient to Insured

Secondary Insurance (click to open)
Secondary insurance Co. Name
Responsible Party

SelfSpouseParent
Name of Insured (secondary)
Address of Insured (if different)
Date of Birth of Insured (secondary)

MonthDayYear
Employer Name
Relationship of patient Insured

Emergency Contact*
Relationship*
Phone*
Can we discuss medical conditions with other members of your family household?*

YesNoOther
Primary Physician (put N for none)*
Phone #
Referring Physician (put N for none)*
Phone #
Patient's Race*

WhiteAmerican Indian or Alaska NativeAsianBlack or African AmericanOther
Patient's Ethnic Group*

Not Hispanic or LatinoHispanic or LatinoUnknown
Pharmacy Name*
Pharmacy Address*
Pharmacy Phone*
How did you hear about our practice? Who referred you?*
Would you like a chaperone during exam?

yesno
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.
Patient or Responsible Party Signature*

Clear
HEALTH HISTORY
Chief complaint*
How long have you had this complaint?*
Are you having any rectal bleeding?*

yesno
If yes, is the bleeding bright or dark?

bright reddark red
If yes, is the blood mixed with the stool or not mixed with the stool?

mixednot mixed
Do you have any blood on the toilet paper?*

yesno
Do you have blood in the toilet water?*

yesno
Do you feel your rectum is falling out of your anus?*

yesno
If yes, does the rectum go back in spontaneously?

yesno
If yes, do you ever have to push the rectum back in manually?

yesno
If yes, have you ever been unable to push the rectum back in?

yesno
Do you have severe pain around the anus?*

yesno
Do you feel a ripping at the anus with bowel movements?*

yesno
Do you have itching/burning at the anus?*

yesno
Did you ever have anal warts?*

yesno
Do you have drainage from the anus?*

yesno
Are you incontinent to solid stool?*

yesno
Are you incontinent to liquid stool?*

yesno
Are you incontinent to gas?*

yesno
In mothers, did you have birthing trauma that required stitches?

yesno
Do you have abdominal pain or cramps?*

yesno
If yes, what is the location?
Has anyone in your family had colon cancer at age less than 50?*

yesno
Has anyone in your family had colon polyps?*

yesno
Has anyone in your family had more than 10 colon polyps?*

yesno
Do you need antibiotics prior to dental procedures?*

yesno
Height (feet ' inches)*
Weight (lbs)*
Allergies*

NoneYes - please list them, include name, dose, and when taken - separated by comma or semicolon
Past Medical History

DiabetesAsthmaEmphysemaArthritisMigrainesAnxietyDepressionHepatitisDiverticulosisFibromyalgiaLiver diseaseRheumatic FeverHigh cholesterolHigh blood pressureIrritable bowel syndrome (IBS)Stomach (gastric) ulcerKidney stonesEnlarged prostateAbnormal heart rhythm (eg. A fib)Heart valve damageHeart murmurHeart attack (coronary arter disease)AnemiaChronic back painCrohn's diseaseUlcerative colitisColon polypsColon cancerBreast cancerUterine cancerHIVProstate CancerGlaucomaStrokeBlood clotsKidney disease
Other medical conditions
Previous Surgeries*

NoneYes - please list them (when?), separated by comma or semicolon
Medications*

NoneYes - please list the medications or substance and your reaction. Include seasonal and food allergies, separated by comma or semicolon
Are you taking Aspirin?*

yesno
Are you allergic to latex?*

yesno
Are you allergic to IV dye?*

yesno
Are you taking Plavix?*

yesno
Are you allergic to peanuts?*

yesno
Are you allergic to shellfish?*

yesno
Social History:
Do you smoke?*

yesno
If yes, how many years?
...and how many packs per day?
Do your drink alcohol?*

yesno
If yes, daily?

yesno
Family History (please specify which family member had any of the following conditions)
Colon polyps
Colon cancer
Ulcerative colitis
Crohn's disease
Familial polyposis
Breast cancer
Uterine cancer
Diabetes
Heart disease
Strokes
Review of Systems:
Eyes:
Have your eyes turned yellow?*

yesno
Have your eyes turned yellow?*

yesno
Head, ears, nose, throat and neck:
Do you have loose teeth?*

yesno
Any chronic sinus problems?*

yesno
Any frequent nose bleeds?*

yesno
Do you have sleep apnea?*

yesno
Cardiac:
Do your legs ever swell up?*

yesno
Do you have chest pain?*

yesno
Does your heart ever flutter?*

yesno
Do you ever get light-headed?*

yesno
Lungs:
Do you get short of breath?*

yesno
Do you have a chronic cough?*

yesno
Gastrointestinal:
Have you been nauseated recently?*

yesno
Have you been vomiting recently?*

yesno
Are you constipated?*

yesno
Have you been having diarrhea recently?*

yesno
Genitourinary:
Do you urinate often during the night?*

yesno
Do you get urinary infections?*

yesno
Do you have blood in the urine?*

yesno
Any pain/burning when you urinate?*

yesno
Neurologic:
Do you have headaches?*

yesno
Any recent slurring of your speech?*

yesno
Are you sensitive to light?*

yesno
Have you ever been temporarily blind?*

yesno
Integuments:
Any skin ulcers?*

yesno
Dry skin?*

yesno
Any breast pain or masses?*

yesno
Any unusual rashes?*

yesno
Psychiatric:
Feeling down?*

yesno
Hearing voices?*

yesno
Trouble concentrating?*

yesno
Endocrine:
Gaining weight?*

yesno
Losing weight (not intentional)?*

yesno
Hematologic:
Bleeding problems?*

yesno
Prior blood clots?*

yesno
Sickle cell disease?*

yesno
Musculoskeletal:
Difficulty walking?*

yesno
Do your joints hurt?*

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

yes
Date:
If yes, by whom?
Barium enema

yes
Date:
Colonoscopy

yes
Date:
If yes, by whom?
CT scan of abdomen/pelvis

yes
Date:
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.
Patient Signature*

Clear
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
I acknowledge and understand the Notice of Privacy Practices for the office of LM Prasad MD SC.*

yes
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*

yesno
Leave message of NORMAL test results on my home answering machine or with a specified family member*

yesno
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:
Designated Person*
Phone Number of the Designated Person*
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*

yesno
If YES, please provide your email address
example@example.com
I understand the information provided to me in the Privacy Notice and I have indicated my response to the questions in each section
Patient (or Guardian) Signature*

Clear
Phone Number*
Please enter a valid phone number.
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*

I acknowledge the Advanced Beneficiary Notice and agree to pay $200 for the clipping procedure in addition to other payment responsibilities according to the insurance contract.I refuse the clipping procedure and accept the risks associated with leaving the colonic defect open (possibility of colonic perforation or bleeding) or incorrect tumor localization.
I acknowledge and understand the Colonoscopy Surgical Coding Guidelines*

yes
Patient Signature*

Clear
Should be Empty:

PATIENT DEMOGRAPHIC AND HISTORY

PATIENT INFORMATION

INSURANCE INFORMATION

HEALTH HISTORY