Colorectal Surgery Institute Methodist Hospital of Southern California

“Hospital-Based” Outpatient Services Billing Information & Frequently Asked Questions

The Colorectal Surgery Institute is part of Methodist Hospital of Southern California and as such operates as a fully licensed Outpatient Department of the Hospital. This means that the Colorectal Surgery Institute provides what is called “hospital-based” outpatient services to its patients. Below we will explain how “hospital based “outpatient services work for you.

DO “HOSPITAL-BASED” OUTPATIENT CENTERS BENEFIT YOU Because we are a “Hospital-Based” Outpatient Center, all of the extensive federal and state licensing requirements and quality standards that apply to Methodist Hospital of Southern California in general also apply to the Colorectal Surgery Institute. In addition, you continue to benefit from the same physician expertise and caring staff to take care of your health care needs.

DO “HOSPITAL-BASED” OUTPATIENT SERVICES COST MORE Depending on your health insurance coverage, you may pay more for some outpatient services and procedures. We recommend that you review your insurance benefits or talk with your insurance carrier about your policy to determine what out-of-pocket expenses you may incur.

HOW YOU WILL BE BILLED When you receive services at the Colorectal Surgery Institute, you will receive two bills: • You will receive a bill for professional services from your treating physician. • You will receive a bill from Methodist Hospital of Southern California for the facility and technical services of the hospital staff in connection with your visit. This is because the Colorectal Surgery Institute clinic space, equipment and staff are funded by the hospital.

WILL THIS AFFECT YOUR HEALTH INSURANCE Co-insurance/co-payments and/or deductibles not covered by your health plan will continue to be your responsibility. Because you will receive separate billing from your treating physician and Methodist Hospital of Southern California, you will have a separate co-insurance/co- payment obligation for each. This may also apply to HMO plans. Please verify your “Hospital Outpatient” Benefits.

WILL THIS AFFECT MEDICARE PATIENTS If you are a Medicare recipient, you will be responsible for two co-payments; one for the physician services (part A), and one from Methodist Hospital of Southern California for facility and procedural services (part B). For patients with Medicare supplemental insurance coverage, some or all of your co-insurance obligations may be covered by such insurance.

CALL US WITH ANY QUESTIONS OR CONCERNS THAT YOU MAY HAVE Please do not hesitate to call the Colorectal Surgery Institute at 626-898-8234 to answer your questions. We’re here to help you.

Colorectal Surgery Institute at Methodist Hospital of Southern California 301 West Huntington Drive Suite 618 • Arcadia, CA 91007 • PH 626-898-8234 • FX 626.898.8235 • www.methodisthospital.org

PATIENT MEDICAL HISTORY

Date: / / Name: Age: Sex: Race: Marital Status: S M Div Wid Sep Occupation: Referring Diagnosis:

REFERRED BY: Physician Glendale Memorial Hospital Family Friend Website Facebook

REFERRING PHYSICIAN: Address: City: State: Zip:

PLEASE LIST THE NAMES OF OTHER PHYSICIANS CARING FOR YOU Primary Care Physician: Name: City/State: Internist: Name: City/State: Gastroenterologist: Name: City/State: Cardiologist: Name: City/State: Oncologist: Name: City/State: Other: Name: City/State:

CHIEF COMPLAINT (and duration):

HISTORY OF PRESENT ILLNESS:

FAMILY HISTORY OF COLON PROBLEMS:

FAMILY HISTORY OF ANY TYPE OF CANCER:

LIST PERTINENT FAMILY, SOCIAL &/OR PERSONAL HISTORY Use This Space for Additional Information Anesthetic Complications: Alcohol: Tobacco: Recreation Drugs:

LIST ALL PREVIOUS SURGICAL PROCEDURES & COLONOSCOPIES Date: Date: Date: Date:

Page 1 of 3 CHECK APPROPRIATE BOXES – No check means not asked Have You Ever Had: Yes No ? Major trauma YOUR PHARMACY CONTACT INFORMATION: Yes No ? Heart attack or heart condition Pharmacy name: Yes No ? Stroke/TIA Address: Yes No ? Alcoholism/Drug Abuse Yes No ? Diabetes Type I-II Phone: ( ) Fax: ( ) Yes No ? Venereal disease Yes No ? Communicable disease such as TB, Typhoid fever, Amebiasis, etc. Yes No ? Hepatitis LIST ALL DRUGS THAT YOU TAKE ROUTINELY Yes No ? MRSA, CDIFF Drug Dose/Day How Long Yes No ? Blood or plasma transfusion reaction Yes No ? Horse serum (TAT, GAT) reaction Yes No ? Penicillin or Sulfa reaction Yes No ? Anxiety, depression, bipolar Yes No ? Increased cholesterol Yes No ? Increased triglycerides Yes No ? Chronic heart failure Yes No ? Renal insufficiency/failure Yes No ? Cancer Yes No ? Blood thinners Yes No ? Asthma, emphysema, COPD (chronic Obstructive pulmonary disease) Yes No ? Autoimmune Disease Other: LIST ALL KNOWN DRUG (OR OTHER) ALLERGIES BELOW AND TYPE OF REACTION (I.E.: RASH, ANAPHYLAXIS, SHORTNESS OF BREATH, ETC.) WITHIN THE PAST SIX MONTHS, HAVE YOU TAKEN: Drug Reaction Yes No ? Digitalis Yes No ? Anti-convulsants Yes No ? Anti-hypertensive agents Yes No ? Corticosteroids Yes No ? Narcotics Yes No ? Blood thinners

Use This Space for Additional Information IMMUNIZATION HISTORY: Tetanus Date: Pneumonia Date: Influenza Date: Polio Date: Measles, Mumps, Rubella Date: Other Date:

REVIEW OF CURRENT SYMPTOMS: Check appropriate box

GENERAL: Yes No ? Chills Yes No ? Fever Yes No ? Weight Change Yes No ? Skin Change

Page 2 of 3 – Patient Medical History Review of Current Symptoms (continued) EYES: Use This Space for Additional Information Yes No ? Loss of Vision Yes No ? Double Vision Yes No ? Eye Pain ENT: Yes No ? Ear Pain Yes No ? Deafness Yes No ? Bleeding Nose Yes No ? Hoarseness Yes No ? Difficulty Swallowing CARDIORESPIRATORY: Yes No ? Cough Yes No ? Chest pain or Shortness of Breath Yes No ? Blood with Coughing Yes No ? Leg Swelling GASTROINTESTINAL: Yes No ? Poor Appetite Yes No ? Nausea and Vomiting Yes No ? Constipation or Diarrhea Yes No ? Change in Bowel Habits Yes No ? Jaundice Yes No ? Abdominal Pain Yes No ? Anal Bleeding Yes No ? Anal Pain GENITOURINARY: Yes No ? Frequency, Urgency, or Incontinence Yes No ? Urgency Yes No ? Blood in Urine Yes No ? Stones or Gravel Yes No ? Urethral Discharge Yes No ? Incontinence NEUROPSYCHIATRIC: Yes No ? Headaches Yes No ? Seizures Yes No ? Paralysis Yes No ? Anxiety/depression Yes No ? Disturbance of Gait or Speech Yes No ? Disturbing Feelings or Thoughts MUSCULOSKELETAL: Yes No ? Back Pain Yes No ? Bone Infections Yes No ? Skeletal Deformities Yes No ? Joint Pain or Swelling Yes No ? Varicose Veins Yes No ? Leg Ulcers OB-GYN # Pregnancies # Vaginal Deliveries # C-Sections Yes No ? Episiotomy – If yes, # Yes No ? Non-menstrual bleeding Yes No ? Excessive Menstrual Flow Yes No ? Irregular Menstrual Flow Yes No ? Pelvic Pain Last Menstrual period

Page 3 of 3 – Patient Medical History Directions to Colorectal Surgery Institute 301 W. Huntington Drive, Suite 618, Arcadia, CA 91007

From the east:

Take the 210 Frwy westbound towards Pasadena. At Santa Anita Avenue, exit and turn left. At Huntington Drive, turn right and stay to the far right. You will see Santa Anita Racetrack on the right and the hospital on the left. Drive passed Hale Medical building and you will see Santa Anita Medical Plaza. Turn right into the driveway and park.

From the west (Glendale or Pasadena):

Take the 210 Frwy eastbound towards San Bernadino. At Santa Anita Avenue, exit and turn right. At Huntington Drive, turn right and stay to the far right. You will see Santa Anita Racetrack on the right and the hospital on the left. Drive passed Hale Medical building and you will see Santa Anita Medical Plaza. Turn right into the driveway and park.

From the south:

Take the 605 Frwy northbound. When you reach the 210 Frwy, take the 210 Frwy westbound towards Pasadena. At Santa Anita Avenue, exit and turn left. At Huntington Drive, turn right and stay to the far right. You will see Santa Anita Racetrack on the right and the hospital on the left. Drive passed Hale Medical building and you will see Santa Anita Medical Plaza. Turn right into the driveway and park.

From the south using surface streets:

The best way to reach the hospital through surface streets is by traveling north on Santa Anita Avenue. At Huntington Drive, make a left and move to the far right. You will see Santa Anita Racetrack on the right and the hospital on the left. Drive passed Hale Medical building and you will see Santa Anita Medical Plaza. Turn right into the driveway and park.

Or travel east on Huntington Drive pass Baldwin Avenue. Stay to the left and remain on Huntington Drive where the road splits. Turn left on Centennial Avenue (just passed the hospital). Next turn left on Huntington Drive and move to the far right as soon as possible. Drive pass the Hale Medical building and you will see Santa Anita Medical Plaza. Turn right into the driveway and park.

If you need further instruction​s, use our Direction Hotline, 626-898-8400.

Colorectal Surgery Institute at Methodist Hospital of Southern California 301 West Huntington Drive Suite 618 • Arcadia, CA 91007 • 626-898-8234 p 626.898.8235 f • www.methodisthospital.org 301 W. Huntington Drive Suite 618 Arcadia, CA 91007

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