OFFICE POLICIES, AGREEMENTS & REGISTRATION FORMS

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

OFFICE AGREEMENTS

FIRST: Please complete the form related to the doctor that you are visiting

1) Dr. Farshid Rahbar LA Integrative GI Registration Form
DOWNLOAD/PRINT PDF | Fill Out & Submit Online

OR

1) Dr. Dipti Sagar Registration Form
DOWNLOAD/PRINT PDF | Fill Out & Submit Online

SECOND: Complete the following forms

2) Online Communication Rules of Engagement
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3) Notification and Discussion of Results
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4) Telephone or Video Conferencing Consent
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THIRD: Read and Learn more about the following:

5) “MUST READ” Page
VIEW

6) ABN Form AND General Information for Medicare Patients:
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
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DISCLOSURES & DISCLAIMERS

1) Disclosures & Disclaimers Prior to Endoscopy and Colonoscopy Surgery Scheduling
VIEW

2) Disclosures & Disclaimers – Procedure Request Form
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3) Disclosure & Disclaimers on Lab Testing
VIEW

4) Disclosures & Disclaimers – Collaboration of Physicians
VIEW

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
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