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
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
2) Online Communication Rules of Engagement – Version 2020
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
3) Notification and Discussion of Results – Version 2020
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
4) Telephone or Video Conferencing Consent
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
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)
VIEW
MEDICAL HISTORY FORM
1) Medical History Form (Paper Format) – Version 2020
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
CONSENTS GENERAL INFORMATION FOR ENDOSCOPY & COLONOSCOPY
1) Colonoscopy and Endoscopy General Consent Information
DOWNLOAD/PRINT PDF VIEW
TERMS & CONDITIONS
1) AthenaHealth Patient Portal Terms and Conditions
DOWNLOAD/PRINT PDF VIEW
DISCLOSURES & DISCLAIMERS
1) Disclosures & Disclaimers Prior to Endoscopy and Colonoscopy Surgery Scheduling
VIEW
2) Procedure Request Form
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
3) Disclosure & Disclaimers on Lab Testing
VIEW
ADDITIONAL DOCUMENTS
1) Third Party Billing & Guarantor Agreement
DOWNLOAD/PRINT PDF
2) Patient REQUEST for Medical Records from Our Office
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
3) Current Medications & Supplements
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
4) Credit Card Authorization Form
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
5) Procedure Request Form
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
6) Patient AUTHORIZATION for Release of Records from Other Sources to Our Practice
DOWNLOAD/PRINT PDF | Fill Out & Submit Online
7) Heidelberg Form
Fill Out & Submit Online
