OFFICE POLICIES, AGREEMENTS & REGISTRATION FORMS

Please review, complete & sign the forms below at least 24 hours before your appointment time


OFFICE AGREEMENTS

1) LA Integrative GI Registration Form – Version 2020
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2) Online Communication Rules of Engagement – Version 2020
DOWNLOAD/PRINT PDF | Fill Out & Submit Online

3) Notification and Discussion of Results – Version 2020
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4) Telephone or Video Conferencing Consent
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5) ABN Form for Medicare Patients:
>> Holistic Consultation & Heidelberg Test
>> SIBO Breath Testing

Please Login to Your Patient Portal to sign these forms or ask our office to provide you with the forms.

“MUST READ” Page (last updated February 2020)
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MEDICAL HISTORY FORM

1) Medical History Form (Paper Format) – Version 2020
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CONSENTS GENERAL INFORMATION FOR ENDOSCOPY & COLONOSCOPY

1) Colonoscopy and Endoscopy General Consent Information
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TERMS & CONDITIONS

1) AthenaHealth Patient Portal Terms and Conditions
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DISCLOSURES & DISCLAIMERS

1) Disclosures & Disclaimers Prior to Endoscopy and Colonoscopy Surgery Scheduling
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2) Procedure Request Form
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3) Disclosure & Disclaimers on Lab Testing
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ADDITIONAL DOCUMENTS

1) Third Party Billing & Guarantor Agreement
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2) Patient REQUEST for Medical Records from Our Office
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3) Current Medications & Supplements
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4) Credit Card Authorization Form
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5) Procedure Request Form
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6) Patient AUTHORIZATION for Release of Records from Other Sources to Our Practice
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7) Heidelberg Form
Fill Out & Submit Online