CONSULTATION BY REFERRAL ONLY
PATIENT INFORMATION SHEET
BOARD CERTIFIED IN GASTROENTEROLGY & INTERNAL MEDICINE
OFFICE HOURS
MONDAY - FRIDAY: 8AM - 12NOON
MONDAY - THURSDAY: 1PM - 5PM / CLOSED FRIDAY 12 NOON
ADDRESS
130 PERPETUAL SQUARE, ANDERSON, SC 29621
PHONE: (864)224-8659 / FAX: (864)222-1303
PATIENT NAME: __________________
APPOINTMENT DATE/TIME: __________________
WELCOME TO OUR GASTROENTEROLOGY PRACTICE. YOUR FIRST VISIT IS AN OFFICE CONSULTATION VISIT ONLY. YOUR PROCEDURE AND ANY RELATED PREPARATION WILL BE DISCUSSED ON A ONE ON ONE BASIS WITH YOU DURING THIS VISIT. ENSURE YOU BRING/ARRANGE AND RE-CHECK WITH YOUR REFERRING PHYSICIAN THE FOLLOWING BE PRESENT / BROUGHT BY YOU FOR THIS VISIT SO THAT YOUR APPOINTMENT DOES NOT GET RESCHEDULED:
- FILLED OUT PATIENT REGISTRATION FORMS
- YOUR INSURANCE CARDS
- A PHOTO ID
- RECENT X-RAYS, PROCEDURE REPORTS, CT-SCANS, TEST RESULTS ETC
- RECENT OFFICE VISITS FROM OTHER PHYSICIANS
- PHYSICIAN REFERRAL FORMS AS PER YOUR INSURANCE PLANS WHEN REQUIRED TO SEE A SPECIALIST
- ALL CURRENT MEDICATIONS-BOTH PRESCRIPTIONS AND OVER-THE-COUNTER
- FOR MAIL ORDER PHARMACIES WE NEED THE NAME, ADDRESS, PHONE NUMBER, FAX AND ANY OTHER DETAILS TO SEND IN YOUR ORDERS DURING YOUR OFFICE VISIT.
- THE LABORATORY NAME AND PHONE #WHERE YOUR INSURANCE COMPANY IS IN NETWORK
IF YOU CANNOT KEEP YOUR APPOINTMENT, PLEASE CALL 24-48 HOURS IN ADVANCE SO THAT AN EMERGENT PATIENT CAN BE SEEN IN YOUR CANCELLED SLOT. ALLOW PLENTY OF TIME TO FIND OUR OFFICE. IF YOU ARRIVE LATE WE WILL MAKE EVERY EFFORT TO SEE YOU ON THE SAME DAY, BUT YOU MAY BE RESCHEDULED TO ANOTHER DAY.
REFILLS MAY REQUIRE EXTRA AUTHORIZATION PAPERWORK AND TIME. SO PLEASE PLAN AHEAD. REQUEST REFILLS WELL BEFORE YOU RUN OUT OF YOUR MEDICATION. IT IS THE RESPONSIBILITY OF EACH PATIENT TO ASK FOR REFILLS AND UPDATE THEIR MEDICATION LIST AT EACH OFFICE VISIT, REFILLS ON MAINTENANCE MEDICATIONS CAN BE OBTAINED BY CALLING YOUR PHARMACY. THE PHARMACY WILL THEN CONTACT US. WE ARE NOW SUBMITTING MOST PRESCRIPTIONS ELECTRONICALLY TO PHARMACIES. THIS INCLUDES SOME MAIL ORDER COMPANIES. AS NOTED ABOVE PLEASE BRING IN THIS INFORMATION. CONTROLLED SUBSTANCES FOR PAIN, ANXIETY ETC WILL BE REFILLED ONLY DURING REGULAR OFFICE HOURS. PRIOR AUTHORIZATIONS FOR MEDICATIONS REQUIRES US TO REVIEW YOUR CHART AND SUBMIT INFORMATION TO YOUR INSURANCE COMPANY FOR APPROVAL AND HENCE MAY TAKE SEVERAL DAYS TO GET A RESPONSE.
FOR EMERGENT MEDICAL NEEDS CALL 911.
TEST RESULTS: THE NATURE AND COMPLEXITY OF THE RESULTS WILL DETERMINE HOW THEY WILL BE REPORTED TO YOU. POSSIBILITIES INCLUDE: OFFICE VISITS, MAIL, TELEPHONE CALL OR PATIENT PORTAL.
BILL PAYMENT: WE GENERALLY FILE ON YOUR BEHALF WITH YOUR INSURANCE COMPANY. HOWEVER, INSURANCE REIMBURSEMENTS ARE NOT A SUBSTITUTE FOR ALL PAYMENTS DUE. PLEASE COME PREPARED TO PAY YOUR OUT OF POCKET COSTS: CO-PAY, CO-INSURANCE, NON-COVERED SERVICES, AND/OR DEDUCTIBLES FOR YOUR INITIAL OFFICE VISIT AND SELF PAY AMOUNTS. IF WE ARE OUT OF NETWORK WITH YOUR INSURANCE, YOU WILL BE EXPECTED TO PAY AT THE TIME OF SERVICE. YOU WILL GET MONTHLY STATEMENTS SHOWING HOW YOUR PAYMENTS HAVE BEEN APPLIED SHOWING ANY AMOUNTS DUE FROM YOU. ANY OVERPAYMENT WILL BE REFUNDED.
OCCASIONALLY, WE ORDER LABS WHICH ARE DONE AT OTHER FACILITIES THAT MAY BE OUT-OF- NETWORK WITH YOUR INSURANCE. PLEASE DISCUSS THIS WITH THE FACILITY AND INSURANCE COMPANY BEFORE YOUR LABS ARE DRAWN.