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
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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.
Once logged in to Your Patient Portal, click on My health on the left bar, then on the top bar click on Medical forms and the ABN Forms for Medicare Patients are there for you to sign electronically.
“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