North Raleigh Gastroenterology, P.A. Patient Demographics

Name: Today’s Date: First MI Last Social Security #: Date of Birth:

Address: Street City State Zip Phone: ____ Alt Phone:

Is it ok to leave a detailed message? Email:______Preferred office?

Employer: Work Phone #:

Marital Status: Gender: Race: Ethnicity:

In case of emergency, contact:

Relationship and Phone #:

Your primary care physician? ______Your pharmacy? ______Address Phone

Your health insurance company:______

Health insurance ID/Member/Subscriber number: ______

Group number ______

I agree to the NRGI patient portal terms of use. Initial

I authorize NRGI to use email communication. Initial

I authorize the release of any medical information necessary to provide care or to process claims and authorize payment to the physician for services rendered. I have read and agree to North Raleigh Gastroenterology's financial policy. I have received a copy of the Notice of Privacy Practices.

Signature NRGI Patient History Questionnaire

Name______Date of birth______Today's date ______

Briefly describe your GI problems during the last 3 months. ______Have you had any nausea? (Feeling like you are going to throw up) Yes No Have you vomited? (Actually thrown up) Yes No ______Have you had heartburn? (Burning feeling in your chest or throat, also referred to as reflux) Yes No

Have you had dysphagia? (Trouble swallowing or food getting stuck in esophagus) Yes No ______Have you had any abdominal pain? Yes No a. If yes, please rate it on a scale of 1-10 ______(1 is very mild, 10 is severe) b. Location of pain? Right Left Upper Lower (above belly button) (below belly button) Are you having any of the following gas symptoms? a. Belching Yes No b. Abdominal bloating (stomach is visibly distended at times) Yes No c. Flatulence (passing gas) Yes No ______Are you having diarrhea? (Loose or watery bowel movements) Yes No

Are you having constipation? (Infrequent bowel movements) Yes No

How many bowel movements per day are you having? (If variable, give an average number per day) ______per day

Are you having any rectal bleeding? Yes No ______Have you had any unexplained weight loss? Yes No a. If yes, please enter the number of pounds lost. ______pounds

Have you taken antibiotics recently? Yes No If yes, when ______what antibiotic? ______Have you traveled outside of the United States in the past year? Yes No If yes, when ______where?______

Is there any family history of a. Colon cancer? Yes No b. Inflammatory bowel disease (Crohn's or Ulcerative Colitis)? Yes No c. Celiac disease? Yes No

10/31/16 North Raleigh Gastroenterology, P.A. NRGI Patient Past Medical History

Name ______Date of birth ______Today's date ______

Medication history ALLERGIES ______

Are you allergic to: SOY EGGS PEANUTS LATEX NO allergies to these items

Describe your reaction ______

List all medication including over the counter, vitamins, supplements, and herbals Name of drug Strength Frequency taken ______

Do you take blood thinners? YES NO Do you have a blood clotting disorder? YES NO

Do you take any of the following?

Aspirin Aleve BC/Goody's Powder Motrin Arthritis Meds Ibuprofen

Coumadin Plavix Lovenox Xarelto Warfarin Effient

Pradaxa Aggrenox Brilinta Eliquis None of these

Medical history Height: ______Weight: ______

Do you have or have you had any of the following?

Cardiac: High blood pressure Pacemaker A Fib Heart valve replacement Irregular heart beat Stent Heart failure High cholesterol Angina Defibrilllator Heart attack NONE of these

Pulmonary: Asthma COPD Emphysema Sleep apnea None of these

GI: Acid reflux Barrett's esophagus Crohn's disease Ulcerative Colitis Colon polyps Celiac disease Diverticulitis Colon cancer Hepatitis Pancreatitis Ulcers Liver disease

GU: BPH Urinary incontinence Abnormal menses Dialysis Kidney problems Urinary tract infections None of these

Endocrine: Diabetes Thyroid None of these

Neuromuscular: Stroke/TIA Parkinson's Migraines Seizures None of these

Psychologic: Depression Anxiety Bipolar disorder Schizophrenia None of these

North Raleigh Gastroenterology, P.A. NRGI Patient Past Medical History

MISC: Anemia Lupus HIV/AIDS Rheumatoid disorder None of these

Cancer: Colon Stomach Other:______None

Chemotherapy? YES NO Radiation? YES NO

Other illnesses: ______None

Are you currently pregnant? YES NO Are you currently breastfeeding? YES NO

Family history Please indicate which family member has had any of the following: NONE

Esophageal cancer ______Stomach cancer ______

Colon cancer ______Crohn's ______

Liver disease ______Ulcerative colitis______

Pancreatic cancer ______Celiac disease ______

Other ______

Surgical/Endoscopy history Have you ever had a problem with anesthesia? YES NO If so, please describe ______

Have you had any of the following surgeries or procedures? If so, when? NONE

Colon cancer screening Upper endoscopy

Colonoscopy Cardiac surgery

Heart stent Vascular surgery

Gallbladder Appendectomy

Hysterectomy Breast biopsy/surgery

Colon surgery Valve replacement

Obesity surgery Joint surgery

Other surgical history ______

North Raleigh Gastroenterology, P.A. NRGI Patient Past Medical History

Social history

Occupation ______

Marital status Single Married Divorced Widowed

# of children ______

Tobacco use Never Former Active ______packs a day

Alcohol use Never Former Active ______drinks per week

Illegal drug use Never Former Active

Exercise None Light Moderate Heavy

Please save your completed form and return to our practice by fax (844-587-9567) or email ([email protected]). **Important** Please check to see that your answers were saved before closing the document. For additional help, please see our troubleshooting guide. N North Raleigh Gastroenterology, P.A. R Rajat Chander, M.D. G Phone: (919) 846-9011 Fax: (844) 587-9567 I www.nrgi.org

NRGI Financial Policy

§ Patients must pay their copay/co-insurance at the time of service. § You are responsible for making sure your primary care physician issues insurance-required referrals. § Our office will bill your insurance company for all services, but you remain responsible for ensuring payment. § When your insurance company responds, our office will bill you directly for your deductible, co- insurance, and services not covered by your policy. § You will be expected to pay in full for any services your insurance company deems related to a pre-existing condition. § We accept Visa, Mastercard, American Express, Discover, check or cash. § You are expected to pay your portion within 30 days of the bill date. § All past due accounts are charged a $10 fee and sent to an outside collections agent. § Patients are expected to notify our office immediately of insurance changes. § Please contact us (919-846-9011) and ask for our billing staff if you need an explanation of your bill. Policy for endoscopic procedures (colonoscopy and upper endoscopy)

Dr. Rajat Chander will perform your procedure at either the Raleigh Endoscopy Center or WakeMed Cary Hospital. Your insurance company will be billed three fees. Dr. Chander’s office will bill a professional fee, Raleigh Endoscopy Center/WakeMed Cary Hospital will bill a facility fee, and Carolina Sedation Services will bill for anesthesia. If any tissue biopsies are required, a pathologist will examine them, and there will be a fourth fee generated by the pathologist. Colonoscopies and endoscopies are surgical procedures. If your insurance policy covers your surgery, payment will be subject to the deductible and co-insurance amounts specified by your policy. Every insurance policy is different. Please call the member services department of your insurance company if you have questions about how your policy covers outpatient surgery.

We want to emphasize that as medical providers, our relationship is with you, the patient, not your insurance company. While we file insurance claims as a courtesy to our patients, all charges are your responsibility from the date service is rendered.

If you have any questions about the above information, please do not hesitate to ask us. We are here to help you and consider it a privilege to serve you. NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.

State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on 4/1/2004 and will remain in effect until it is amended or replaced by us.

It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Noticewill be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.

You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, Erin Bell. Information on contacting us can be found at the end of this Notice.

TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION

We will keep your health information confidential, using it only for the following purposes:

Treatment: We may use your health information to provide you with our professional services. We have established “minimum necessary or need to know” standards that limit various staff members’ access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.

Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.

Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.

Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x- rays or other similar forms of health information and/or supplies unless you have advised us otherwise.

Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.

Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.

Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to

North Raleigh Gastroenterology, P.A. medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.

Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so.

National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards or letters.

YOUR PRIVACY RIGHTS AS OUR PATIENT Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.

Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care information. (When we make a routine disclosure of your information to a professional for treatment and/or payment purposes, we do not keep a record of routine disclosures: therefore these are not available.) You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can request non- routine disclosures going back 6 .

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement. (Except in emergencies.) Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing.

QUESTIONS AND COMPLAINTS

You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us. In writing. Request a Complaint Form from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

HOW TO CONTACT US

Practice Name: North Raleigh Gastroenterology, P.A.

Privacy Officer: Amanda KellyRN, BSN, LNC, CGRN

Telephone: (919) 846-9011 Fax: (844) 587-9567

Address: 1505 SW Cary Pkwy, Ste 309 Cary NC 27511

North Raleigh Gastroenterology, P.A. Patient Portal

Our patient portal allows you to send secure messages to our office and pay your bill. If you have agreed to the patient portal terms, you will receive an email from CareCloud to connect with Dr. Rajat Chander and North Raleigh Gastroenterology. By agreeing, you acknowledge that: • The patient portal is not to be used for urgent communications or medical emergencies. If you do not hear back within three buisness days, please call our office directly at (919) 846-9011. • The portal is intended to complement your care, not as a substitute for face to face provider-patient interaction. • Messages sent via the portal will become part of your medical record.

Consent to use of Email

North Raleigh Gastroenterology would like to give you the chance to communicate with your doctors, other healthcare providers (such as nurses), and administrative services by electronic mail (email). Sending private patient information by email, however, has a number of risks that you should think about. Risks of Email • Email may be instantly sent worldwide and be received by many intended and unintended recipients. • Those who get email can pass on messages to anyone without the original sender's permission or knowledge. • Users can easily misaddress an email. • Backup copies of email may exist even after the sender or the recipient has erased their copy. All emails will be kept in your medical record. This means that all people who have access to the medical record will be able to see the emails. • You should not use your employer's email system to send or receive private medical information. If you choose to send or receive an email from your workplace, there is a chance your employer could read the message. • Email messages may not be answered on the same business day. We will make an effort to read and respond to email as soon as possible, but we cannot guarantee that any email message will be answered within any set period of time. Never use email in an urgent situation or in an emergency.

Conditions for the use of Email • If you agree to the use of email, you agree to the following rules: • Your message should be short. If you feel your message is too long for an email, you may wish to call our office or schedule an appointment. • Please write the topic of your email in the subject line. • Please write your name and patient identification number, if known, in the message. • It is the policy of North Raleigh Gastroenterology to make all email messages sent or received that are about medical treatment a part of your medical record. We will treat such email messages with the same amount of confidentiality as other portions of the medical record. • We will make every effort to protect the privacy of email information. Due to the possibility of technical problems, we cannot guarantee the security of all emails. Your use of email is an acknowledgement of this insecurity and your acceptance of the risk. • North Raleigh Gastroenterology may forward email messages as needed for diagnosis, treatment, and reimbursement. North Raleigh Gastroenterology will not pass on the email to others without your prior consent. • Because some medical information is sensitive and the privacy of email is not guaranteed, you should not use email for communications about sensitive information. Some examples are protected diagnoses (such as mental health conditions or substance abuse problems), information about HIV/AIDS, and workers' compensation injuries. • Do not send financial information, credit card numbers, checking account numbers, or any similar information to North Raleigh Gastroenterology by email. We will not ask you for this information by email. Any email supposedly from North Raleigh Gastroenterology asking for credit card or checking account information is fraudulent. Please let us know if you receive such an email. • It is your duty to protect your password or other means of access to email sent or received from North Raleigh Gastroenterology. North Raleigh Gastroenterology is not responsible for breaches of confidentiality caused by the patient. • You may withdraw consent to the use of email at any time by email or written communication with North Raleigh Gastroenterology.

North Raleigh Gastroenterology, P.A.