9821 Greenbelt Rd., #103 Welcome Lanham, MD 20706 Thank you for choosing Greenbelt Endoscopy Center (GEC) for your gastrointestinal endoscopicPhone: services. Our 301-552-1801 Center offers “state of the art” equipment, “pain free” endoscopic procedures, and skilled staff who provide professional care Fax:in a warm 301-552-2695 and caring environment. GEC is dedicated to providing expert services that accommodate the needs of individual patients. We specialize in performing Upper Endoscopy (EGD), Colonoscopy, Capsule Endoscopy (video Camera pill), Hemorrhoid banding, Liver biopsy and Chineseabdominal paracentesis. Line 240-413-8943 This booklet consist of forms and information that you must know before your procedure. Please review it in advance of the date of procedure. PATIENT PROCEDUREwww.greenbeltendoscopy.com INFORMATION PACKET AllWelcome patients must complete the Scheduling Form and Ebola Virus Disease (EVD) Screening at the time of scheduling the procedureThank you appointment.for choosing Greenbelt Endoscopy Center (GEC) for your gastrointestinal endoscopic services. Our Center offers “state of the art” equipment, “pain free” endoscopic procedures, and skilled staff who provide professional care in a warm and caring environment. TableGEC isof dedicated Content: to providing expert services that accommodate the needs of individual patients. We specialize in performing Upper Endoscopy (EGD), Colonoscopy,• Scheduling Capsule form-------------------------------------------------------------------- Endoscopy (video Camera pill), Hemorrhoid banding, Liver biopsy and 2abdominal paracentesis. • Ebola Virus Disease screening form-------------------------------------------- 3 • This booklet consists of formsPatient and Demographics information that andyou must HIPAA know disclosure before your form-------------------------- procedure. Please review it in advance 4-5 of the date of procedure. • Physician ownership disclosure -------------------------------------------------- 6 • All patients must complete• the Scheduling Form at the time of scheduling the procedure appointment. • • Table of Content:• Patient payment notice-------------------------------------------------------------- 10 • • ScreeningScheduling vs formDiagnostic --------------------------------------------------------------------------------------------------------------------------------- vs. Surveillance colonoscopy------------------------------------------------ 11 2 • • InformedPatient Demographics consent and patient and HIPAAHIPAA authorization disclosuredisclosure sample formform--------------------------------- form---------------------------------------------------- 12-143-4 • • ProcedurePhysician informed ownership consent disclosure sample ---------------------------------------------------------- --------------------------------------------------------- form---------------------------------------- 15-16 5 • • HIPAADriving Notice DirectionsDirection--------------------------------------------------------------------------- of Privacy -------------------------------------------------------------------------- practice Omnibus rule 2013------------------------ 17-19 5 • • Patient’sPreparing Right for andyour Responsibilities procedureprocedure----------------------------------------------------------- ------------------------------------------------------------ ------------------------------------------------ 206 -22 • • UnderstandingAnesthesia for Upper your procedureprocedure----------------------------------------------------------- Endoscopy---------------------------------------------------- ----------------------------------------------------------- 23 7 -24 • • UnderstandingArrange ride forcolonoscopy.----------------------------------------------------------- your procedureprocedure-------------------------------------------------------- -------------------------------------------------------- 25-26 8 • ExcellentPatient paymentcolonoscopy notice-------------------------------------------------------------------- bowel preparation------------------------------------------- 27-28 9 • Anesthesia Consent------------------------------------------------------------------------- 9 Screening vs. Diagnostic vs. Surveillance colonoscopy------------------------------10 • Patient payment notice -------------------------------------------------------------------- 10 Patient Authorization sample form----------------------------------------------------- 11-13 Screening vs. Diagnostic vs. Surveillance colonoscopy------------------------------ 11 • Procedure informed consent sample form---------------------------------------------14-15 Assignment of Benefits -------------------------------------------------------------------- 12-13 • HIPAA Notice of Privacy practice Omnibus rule 2013----------------------------- 16-18 Patient Authorization sample form ----------------------------------------------------- 14-16 • Patient’s Right and Responsibilities --------------------------------------------------- 19-20 Procedure informed consent sample form--------------------------------------------- 17-18 • Understanding Upper Endoscopy------------------------------------------------------Note: - 21-22 HIPAA Notice of Privacy practice Omnibus rule 2013 ----------------------------- 19-21 • Understanding colonoscopy.------------------------------------------------------------- 23-24 Patient’s Right and Responsibilities ---------------------------------------------------- 22-23 • Excellent colonoscopy bowel preparation--------------------------------------------- 25 Please• bringExcellentQ&A---------------------------------------------------------------------------------------- colonoscopy this bowel preparationbooklet --------------------------------------------- on the day 2426 of • Q & A ----------------------------------------------------------------------------------------- 25 • COVID - 19 informationthe ------------------------------------------------------------------procedure. 26 Note: Please bring this booklet on the day of the procedure. GreenbeltGreenbelt Endoscopy Endoscopy Center, Center, 9821 9821 Gr eenbeltGreenbelt Road, Road, Suite Suite 101 104, – 103, Lanham, Lanham, MD MD 20706 20706 Tel: Tel: 301-552-1801 301-552-1801 1 Rev. 03/1611/20 Greenbelt Endoscopy Center, 9821 Greenbelt Road, Suite 103, Lanham, MD 20706 Tel: 301-552-1801 1 Greenbelt Endoscopy Center 9821 Greenbelt Road, Suite 103104 Lanham, MD 20706 Tel: (301) 552 – 1801 Fax: (301) 552 – 2697 Scheduling Form To Be Completed By Patient: First Name: ___________________________ Last Name: _____________________________ Date of Birth: ________________ Sex: M / F SS #: _____________ Zip Code: __________ Home Phone #: _________________________ Cell Phone #: __________________________ E-mail: _____________________________ Preferred Method of Contact: Cell Home Dear Patient, Thank you for choosing Greenbelt Endoscopy Center for your upcoming Endoscopy Procedure. This booklet consists of important information regarding to your upcoming procedure at our center. This packet includes: Informed Consent, HIPAA Omnibus Privacy Notice, Patient’s Rights and Responsibilities, Advanced Directive Information, Disclosure of Ownership, as well as financial interests that you must review before your arrival at Greenbelt Endoscopy Center. Please be sure to bring the attached packet with you on the date of your procedure. By signing this form you acknowledge that we may leave any detailed medical related messages through your E-mail, text messages, voice mail / answering machine, or whoever answers the phone. Check this box if you DO NOT wish for us to leave any detailed medical related messages to the person listed below: ______________________________________________________________________________ Your signature below indicates that you have received this booklet titled ‘Patient Procedure Information Packet’ and you agree to review all of the included information prior to your procedure at Greenbelt Endoscopy Center. Patient / Guardian Signature: _______________________________ Date: ________________ Description of relationship to patient: _______________________________________________ For Office Staff Use Only: Does the patient require anesthesia consult? Yes No Is this a colonoscopy screening procedure? ☐ Yes ☐ No Procedure: EGD Colonoscopy Hemorrhoid Banding Capsule Endoscopy Date of Procedure: __________ Time: ________ GI Physician Name: ___________________ Greenbelt Endoscopy Center, 9821 Greenbelt Road, Suite 101 – 103, Lanham, MD 20706 Tel: 301-552-1801 Greenbelt Endoscopy Center, 9821 Greenbelt Road,2 Suite 104, Lanham, MD 20706 Tel: 301-552-1801 2 FORM #44 RV 5/17 Patient Demographics and HIPAA Disclosure Form The information below will remain confidential and will be a part of your patient record. Please complete and return this form to Greenbelt Endoscopy Center on the procedure day. Name: _____________________________________________ Sex: ☐M ☐F Date of birth: ________________ Ethnicity: ☐Hispanic or Latino ☐Not Hispanic or Latino Race: ☐American Indian or Alaska Native ☐Asian ☐Black or African American ☐Native Hawaiian or Other Pacific Islander Caucasian Mailing Address: _________________________________________________ City: ________________________ State: _______________ Zip code: ____________ Email address: ______________________________________ Home phone: ___________________________________ Cell phone: ___________________________________ Emergency contact name: ________________________ Emergency