Procedure Scheduling Form

G A S T R O I N T E S T I N A L M E D I C I N E A S S O C I A T E S , P . C . MYRON SHOHAM, M.D. LEONARD S FISCHER, M.D. R. ALLEN BLOSSER, M.D. SOLOMAN SHAH, M.D. WASEEM AZIZ, M.D. DIPLOMATES OF THE AMERICAN BOARD OF INTERNAL MEDICINE AND DIPLOMATES OF THE SUBSPECIALTY BOARD OF GASTROENTEROLOGY www.gastromedva.com

COLORECTAL CANCER SCREENING and EGD OPEN ACCESS Packet

After careful medical assessment, your healthcare provider has recommended that you have a colonoscopy. Colon cancer is the second leading cause of cancer death in the United States, and colonoscopy is the recommended screening test for any patient over the age of 50. For those with a family history of colon cancer or polyps, colonoscopy is recommended at age 40 or 10 years before the age that family member was diagnosed.

This webpage and downloadable packet are designed to effectively and efficiently guide you through the scheduling process for your colonoscopy procedure without an office visit.

You are invited to proceed with Open Access Colonoscopy if you meet the following criteria:  Colonoscopy is for routine screening, history of polyps/colon cancer, a family history of colon neoplasm, or routine colonoscopy for inflammatory bowel disease in remission  You have NO active symptoms (abdominal pain, a change in bowel habits, etc.)  You do NOT have severe pulmonary or cardiac disease

If you believe that Open Access Colonoscopy is the right option for you, please download the attached packet and complete it, following the directions. You may send the packet (complete with your insurance card and photo ID) to our office via mail, email, or fax. Please allow up to five business days for our office to review your packet and pre-certify your exam. After our medical staff reviews your paperwork, we reserve the right to require an office visit prior to proceeding with your colonoscopy. If that is the case, our scheduling staff will inform you of the reason for your office visit when they call. Once your paperwork is cleared by the medical staff, we will call you to schedule your colonoscopy. If you have not heard from our office within two weeks, please call us at 703-281-1023.

When your colonoscopy is scheduled, we will mail you a packet with your preparation prescription and all instructions. If you have any questions, please do not hesitate to call us.

If you do not meet the criteria for Open Access Colonoscopy, or wish to have an office visit with a member of our medical staff prior to your procedure, please call the office at 703-281-1023, option 3, to schedule an appointment. G A S T R O I N T E S T I N A L M E D I C I N E A S S O C I A T E S , P . C . MYRON SHOHAM, M.D. LEONARD S FISCHER, M.D. R. ALLEN BLOSSER, M.D. SOLOMAN SHAH, M.D. WASEEM AZIZ, M.D. DIPLOMATES OF THE AMERICAN BOARD OF INTERNAL MEDICINE AND DIPLOMATES OF THE SUBSPECIALTY BOARD OF GASTROENTEROLOGY www.gastromedva.com

We look forward to working with you.

Please complete and return the following In addition to the forms in this packet, 6 pages of this packet: please provide our office with:

1. Cover Sheet and Check List An enlarged copy of your insurance card, front  2. Patient Demographics and back 3. HIPAA Consent An enlarged copy of your driver’s license or  4. Colonoscopy Consent photo I.D. 5. Scheduling Consent  Insurance referral if required 6. Medical History Form

This information is needed prior to your colonoscopy procedure. Open Access allows for your colonoscopy or EGD without having to be seen in the office first. Therefore it is imperative that all forms are submitted at once. We cannot schedule your procedure if any forms or I.D. cards are missing.

You may submit your forms in one of 4 ways:

1. Mail: 3. In Person: Gastrointestinal Medicine Associates Monday-Friday, 9am-4pm 3620 Joseph Siewick Drive Ste 307 Fairfax, Virginia 22033 Fairfax office Attn: Open Access

2. Fax: 703-620-2331 4. Email: [email protected] G A S T R O I N T E S T I N A L M E D I C I N E A S S O C I A T E S , P . C . MYRON SHOHAM, M.D. LEONARD S FISCHER, M.D. R. ALLEN BLOSSER, M.D. SOLOMAN SHAH, M.D. WASEEM AZIZ, M.D. DIPLOMATES OF THE AMERICAN BOARD OF INTERNAL MEDICINE AND DIPLOMATES OF THE SUBSPECIALTY BOARD OF GASTROENTEROLOGY www.gastromedva.com

Please be advised that you will have your procedure within 30 days.

Please read all instructions and information contained in this packet thoroughly. You will receive your preparation instructions at the time you are scheduled.

If you have any questions or concerns regarding this procedure, please call the office at 703-281-1023 G A S T R O I N T E S T I N A L M E D I C I N E A S S O C I A T E S , P . C . MYRON SHOHAM, M.D. LEONARD S FISCHER, M.D. R. ALLEN BLOSSER, M.D. SOLOMAN SHAH, M.D. WASEEM AZIZ, M.D. DIPLOMATES OF THE AMERICAN BOARD OF INTERNAL MEDICINE AND DIPLOMATES OF THE SUBSPECIALTY BOARD OF GASTROENTEROLOGY www.gastromedva.com

OPEN ACCESS COLONOSCOPY and EGD COVER SHEET

Patient Name: Number of pages including this cover sheet:

Check List

Cover Sheet Demographic Information Signed HIPAA Consent Signed Colonoscopy and or EGD consent Completed and Signed Procedure Scheduling Form Your Completed Medical History Form (2 pages) Photo ID Insurance Card (front and back) Referral from your primary care physician if required by your insurance

All the information contained in this packet is complete and true to my knowledge.

Patient Signature Date

What is the best way to contact you? ___ Email What time of day should we contact you? ___ Cell ___Morning ___ Work ___ Afternoon ___ Home

Patient Full Name: G A S T R O I N T E S T I N A L M E D I C I N E A S S O C I A T E S , P . C . MYRON SHOHAM, M.D. LEONARD S FISCHER, M.D. R. ALLEN BLOSSER, M.D. SOLOMAN SHAH, M.D. WASEEM AZIZ, M.D. DIPLOMATES OF THE AMERICAN BOARD OF INTERNAL MEDICINE AND DIPLOMATES OF THE SUBSPECIALTY BOARD OF GASTROENTEROLOGY www.gastromedva.com

Address:

City: State: Zip code:

Home # Date of Birth: Age:

Work # Male Female Marital Status: S M D W Social Security Cell # #

Email Address:

Employer: Occupation: Emergency Contact: Phone # Primary Care Physician: City, State: Referring Physician: City, State:

Primary Insurance Information: Secondary Insurance Information: Insurance Name: Insurance Name: Identification # Identification # Group # Group # Policy Holder Policy Holder Name: Name: Relationship to Relationship to Patient: Patient: Holder’s Date of Holder’s Date of Birth: Birth: Social Security # Social Security #

PAYMENT POLICY All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for all fees, regardless of insurance coverage. It is also customary to pay for services when rendered, unless other arrangements have been made in advance with our office. In the event my account is turned over to an attorney for collections, I will pay any fee / costs incurred during the collection process INSURANCE AUTHORIZATION AND ASSIGNMENT I hereby authorize Gastrointestinal Medicine Associates, P.C. to furnish information to insurance carriers (including Medicare / Medigap) concerning my illness and treatments and I hereby assign to the physician(s) all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance(s). I understand I am responsible for a charge of $50.00 for missed appointments without at least 24 hour prior cancellation G A S T R O I N T E S T I N A L M E D I C I N E A S S O C I A T E S , P . C . MYRON SHOHAM, M.D. LEONARD S FISCHER, M.D. R. ALLEN BLOSSER, M.D. SOLOMAN SHAH, M.D. WASEEM AZIZ, M.D. DIPLOMATES OF THE AMERICAN BOARD OF INTERNAL MEDICINE AND DIPLOMATES OF THE SUBSPECIALTY BOARD OF GASTROENTEROLOGY www.gastromedva.com

notice; a $15.00 fee if I don’t pay my co-pay at the time of my visit. I verify that the information provided above is correct.

Signature of Patient Date I hereby give my consent to (name of patient or authorized agent) Gastrointestinal Medicine Associates, P.C. (GMA) to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of

(name of patient)

I acknowledge the review and / or receipt of the physician’s Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information. I understand that the physician has reserved a right to change his or privacy practices that are described in the Notice. I also understand that a copy of a revised Notice will be available to me upon a written request to the Privacy Officer.

I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to the physician. I also understand that I will not be able to revoke this consent in cases where the physician has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the physician’s office.

I understand that I have the right to request that the practice restricts how my individual identifiable health information is used and / or disclosed to carry out treatment, payment or health operations. I understand the practice does not have to agree to such restrictions, but that once such restrictions are agreed to, the practice and their agents must adhere to such restrictions.

I authorize GMA that family members may have access to my records or to act on my behalf in the coordination of my care. (Please choose one)

YES NO

If yes, only those family members listed below may have access to my records.

Signed Date:

If not the patient, please specify your relationship to the patient: Patient Full Name Date Form Completed // DOB // Male Female Insurance Primary Care Physician PCP phone -- Allergies (Office use only) Dx: Height Weight

1 Are you currently experiencing any of these 2. Personal Medical History . symptoms? Please check all that apply Please check all that apply Abdominal pain Hypertension/High Blood Pressure Change in bowel habits Coronary Artery Disease Diarrhea Cancer (Type) Constipation Sleep Apnea or CPAP use Rectal bleeding Asthma/ COPD Mucus in stool Diabetes Loss of appetite Seizures Unintentional weight loss Bleeding problems Gout Other medical issues Heartburn and/or indigestion NONE OF THE ABOVE Problems swallowing/Food getting stuck NONE OF THE ABOVE

3 Current Medications . Please list your medications and dosages for each. Check those that apply and/or attach your own list. Include over the counter medications and supplements. Medication Name Dosage Medication Name Dosage Plavix/Effient  Coumadin/Warfarin  Aspirin  NSAIDS (Ibuprofen,  Naprosyn, etc.) 

4 Social History 5. Family History . Please check all that apply Please check all that apply. Please indicate family member(s) and age of diagnosis. Tobacco Colon Cancer How Colon Polyps Much? Alcohol Stomach Cancer How Esophageal Cancer Much? Caffeine Barrett’s Esophagus How Crohn’s Disease Much? Ulcerative Colitis Gallbladder Disease Peptic Ulcer Disease Gynecological Cancer When was your last physical exam? // Was it normal abnormal? If abnormal why?

Please provide us with your pharmacy information below, we may send your preparation directly to your pharmacy.

Name: Address: Phone Number:

The rest of this page intentionally left blank. 6. Procedure History When was your last procedure? And what were the results? Colonoscopy // Normal or Upper Endoscopy (EGD) // Normal or Flexible Sigmoidoscopy // Normal or I have never had any endoscopies

7. Surgical History or Hospitalizations None Please list all surgeries/hospitalizations dates and reasons // // // // Name______DOB______The medical information provided is complete and true to my knowledge.

______Patient Signature Date

For Office Use Only

1. BMI:______SLEEP APNEA: Yes No 2. Patient scheduled for open access colonoscopy? Yes No, Why not ______3. Reason for procedure: CRCS FHx ______h/o Polyps h/o CRC other______4. STANDARD PREP Other ______5. FOH RHC ASC GCV 6. MAS LSF RAB SSH WIA 7. Patient needs office visit for: ______

MLP Signature ______Date ______

MD Use Only

History reviewed and agreed VS: T______P______R______BP ______GEN: WDWN in NAD abnormal ______EYES: EOMI, anicteric abnormal ______CHEST: CTAB w/r/r abnormal ______COR: RRR m/r/g abnormal ______ABD: NABS soft, NT/ND, g/r abnormal ______EXT: c/c/e abnormal ______MD Signature ______Date ______

COLONOSCOPY INFORMATION AND CONSENT

Colonoscopy is an endoscopic examination of the colon. This procedure is usually done as outpatient and involves the insertion of a flexible scope instrument into the rectum and the entire colon. Colonoscopy may be only diagnostic, or it may be therapeutic, in which case a polyp may be removed or a biopsy may be taken, or a bleed site cauterized using an electrical current. PREPARATION: Please discontinue anti-inflammatory products, and iron one week prior to your procedure date. Please continue all other medications until the day before your procedure. (Please consult with your doctor concerning any medication taken in the morning, especially insulin, blood pressure, seizure, or cardiac medications, as they may be allowed.) Please follow the preparation instructions given to you for the day before. SEDATION: Preoperative medications include an intravenous injection of sedation medication administered by an anesthesiologist to insure the patient is relaxed and comfortable. General anesthesia is not required. Because of the sedation, the patient WILL NOT be allowed to drive him or herself home. Transportation home must be arranged with another person and not by taxi (unless accompanied by an adult.) RISKS: Serious complications of colonoscopy such as intestinal bleeding and/or perforation are infrequent. The risks are slightly greater in the elderly and in individuals who have had multiple abdominal operations, a history of abdominal infections, or prior radiation therapy. Other complications include drug reaction from the sedative medications (such as irritation at the IV site, severe allergic reactions to the medicine), prolonged abdominal pain, prolonged lethargy, etc. This list is not inclusive of all possible risks and complications. Risks of Colonoscopy Diagnostic Therapeutic Bleeding Less than 1% 1.5-2% Perforation Less than 1% Less than 1%

RESULTS: The results of the colonoscopy and/or biopsies will be sent to you and your referring physician in approximately 4-6 weeks. We will provide you with the results of your procedure via a letter or by arranging an office visit for follow-up. If any serious abnormality is identified you will receive a phone call as soon as possible. (Please do not call the office for results by phone.) CONSENT: I have read the above information and understand the indications for a colonoscopy, its potential risks, its potential benefits, and potential complications. I consent to the taking and reproduction of any photographs of the procedure for professional purpose. I hereby authorize and permit M.D. and whomever he may designate as his assistant, to perform upon me the procedure of colonoscopy.

I acknowledge that I have received preparation instructions for this procedure. (Initials)

Print Patient Name Witness

Signature (Patient or legal guardian) Date

PROCEDURE SCHEDULING FORM PLEASE READ THIS FORM CAREFULLY AND COMPLETE ALL SECTIONS

Are you an insulin-dependant diabetic? (If yes, A.M appointments only): YES NO

If you need to schedule, reschedule or cancel any procedures please call us at 703-281-1023 and press the option for the procedure coordinator. Please DO NOT call the facility or leave messages concerning procedure scheduling on the nurses’ voicemail. Your call will be returned by our coordinator within 48 hours. I give my permission for procedure appointment information (not results) to be left: (May check more than one) Left on home answering machine Left with spouse/immediate family Left on cell phone voicemail Left on work voicemail Cell phone # Left with assistant

Due to unavoidable circumstances, the time of my procedure is subject to change due to cancellation and/or emergencies. I understand this is infrequent but may happen. If a change in my procedure time is necessary I will be notified immediately.

I understand that I must notify Gastrointestinal Medicine Associates, P.C. at 703-281-1023 ext. 106 if I wish to cancel my procedure for any non-emergency reason or if my insurance has changed. If I fail to do this within FIVE (5) BUSINESS DAYS of my scheduled time I will be charged $250.00. I understand that work is not an emergency. I understand that if I call to reschedule within two (2) business days of my procedure I will be charged $100.00.

I understand that I cannot drive myself home following my procedure, and that I must be accompanied by someone who will be responsible for taking me home. The use of a taxi or public transportation to go home following my procedure is unacceptable unless I am accompanied by an adult.

I understand that I will be responsible for all costs associated with my procedure and that I may receive bills from the facility, the doctor, anesthesia and pathology. I understand that I am able to call my insurance for coverage information and my out of pocket costs. Due to insurance and healthcare liabilities, I understand that I will need to repeat my office consultation if I do not complete my procedure within 6 months of my last visit. By signing this form I have read and agree to all the above information. I understand I can not be scheduled if I do not sign this form.

Signature (Patient or legal guardian) Date

UPPER GASTROINTESTINAL ENDOSCOPY INFORMATION AND CONSENT

An upper gastrointestinal endoscopy (EGD, gastroscopy) is an examination which enables direct inspection of the esophagus, stomach, and duodenum. There are no x-rays involved with this procedure. A flexible gastroscope (a tube containing light, lens, and biopsy channel) is used for this procedure through which biopsies can be obtained. Neither the Endoscopy nor the biopsy is associated with any pain.

PREPARATION: Unless otherwise stated, we recommend that you do not eat or drink any food or liquid from midnight the evening prior to the procedure. Please discontinue all aspirin, aspirin containing products, and iron one week prior to your procedure. (Please consult with your doctor concerning any medication taken in the morning, especially insulin, blood pressure, seizure, or cardiac medications, as they may be allowed.) SEDATION: Preoperative medications include an intravenous injection of sedation medication administered by an anesthesiologist to insure the patient is relaxed and comfortable. General anesthesia is not required. Because of the sedation, the patient WILL NOT be allowed to drive him or herself home. Transportation home must be arranged with another person and not by taxi (unless accompanied by an adult.) RISKS: There are few risks related to the EGD. Risks of bleeding, perforation, and aspiration of gastric contents into the lung are exceedingly rare, but are somewhat more common in elderly patients. The other significant risks include side effects from medication, such as over sedation or severe allergic reactions, and possible irritation of the vein at the IV site called phlebitis. RESULTS: The results of the EGD and/or biopsies will be sent to you and your referring physician in approximately 4-6 weeks. We will provide you with the results of your procedure via a letter or by arranging an office visit for follow-up. If any serious abnormality is identified you will receive a phone call as soon as possible. (Please do not call the office for results by phone.)

CONSENT: I have read the above information and understand the indications for an EGD, its potential risks, its potential benefits, and potential complications. I consent to the taking and reproduction of any photographs of the procedure for professional purpose. I hereby authorize and permit M.D. and whomever he may designate as his assistant, to perform upon me the procedure of EGD.

I acknowledge that I have received preparation instructions for this procedure. (Initials)

Signature Date