WELCOME TO CAPE FEAR CENTER FOR DIGESTIVE DISEASES, P.A.

Please assist us by completing the Patient Registration Form. The information is necessary for our files and will be considered confidential.

GENERAL PATIENT INFORMATION: REQUESTING PHYSICIAN ______________________________________

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Patient’s Last Name First Name Middle Initial

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Street Address

_________________________________________ _________________ __________________ ________________________________

City State Zip Social Security Number

____________________________ _________________________ _______________________________ ____________________________________________

Home Phone Number Cell Phone Number Work Phone Number Email Address

___________________________ Sex: M _____ F _____ Marital Status: circle Single …. Married …. Divorced …. Widowed …. Other __________ Date of Birth

Ethnicity: Please circle – Hispanic or Latino Not Hispanic or Latino

Race: (Please circle) White…. Black/African American…. Hispanic or Latino.… Asian…. Pacific Islander…. American Indian…. Other_________________

_________________________________________________________________________________ _____________________________________ Employed by Occupation

______________________________________________________________________________________________________________________________ Employer’s Address

________________________________________ __________________________ _____________________________________________ Name of Person(s) to Notify in Case of Emergency Relationship to Patient Emergency Phone Number (other than numbers above)

INSURANCE INFORMATION:

______________________________________________________________________________________________________________________________ Primary Insurance Company

_________________________________________________________________________________ _____________________________________ Address Group/Local Number

_________________________________________________ _____________________________ _____________________________________ Subscriber’s Name Subscriber’s Social Security Number Date of Birth

_________________________________________________ Subscriber’s Employer’s Name

_________________________________________________ Your Relationship to Subscriber: ______ ________ ________ Subscriber’s ID Number Self Spouse Other

______________________________________________________________________________________________________________________________ Secondary Insurance Company

_________________________________________________________________________________ _____________________________________ Address Group/Local Number

_________________________________________________ _____________________________ _____________________________________ Subscriber’s Name Subscriber’s Social Security Number Date of Birth

_________________________________________________ Subscriber’s Employer’s Name

_________________________________________________ Your Relationship to Subscriber: ______ ________ ________ Subscriber’s ID Number Self Spouse Other

Insurance Assignment – Assignment of Insurance Benefits I hereby authorize and request my insurance company to pay directly to the doctor the amount(s) due on my claim for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical and surgical expense. I will be responsible for payment of the difference; and if the nature of the disability be such that it is not covered by the policy, I will be responsible to the doctor for payment of the entire bill. I authorize the release of any medical information necessary for (TPO), treatment, payment and healthcare operations.

Patient’s Signature _______________________________________________________________________ Date ___________________________________

Insured’s Signature ______________________________________________________________________ Date ___________________________________

CFCDD Clinic Form #03 Rev 11/10,06/11,12/12, 10/14

Cape Fear Center for Digestive Diseases, PA

Patient Name: __________________________________________ Date of Birth: _____/_____/_____

Today’s Date: _____/_____/_____ Age: ______ Married/Single/Divorced/Separated/Widowed (Please Circle) Race ____________________ Sex: Male / Female (please circle) Describe briefly the reason for your visit: ________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________ Primary Care Physician: ____________________________ Requesting Physician: _______________________________ Are you presently taking any of the following non-prescription medications? (Please Circle) Aspirin Products: Yes/No If yes, please describe: _______________________________________ Arthritis Medications: Yes/No “ “ “ “ “ ______________________________________ Laxatives/enemas: Yes/No “ “ “ “ “ ______________________________________ Fiber Products: Yes/No “ “ “ “ “ ______________________________________ Antacids/ulcer drugs: Yes/No “ “ “ “ “ ______________________________________ List your other current medications/vitamin supplements; please enter the dose and frequency as well:

Please list drugs/items (ie:Penicillin, Latex) you are allergic to:

Which Pharmacy do you use? (Include location and phone number, if known)___________________________________

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Past Medical History (If yes, to the following questions, please describe.):

Lung Disease: Yes/ No _______________________________________________________________

Cancer (When/Where?): Yes / No _______________________________________________________________

Radiation/Chemotherapy: Yes / No _______________________________________________________________

Heart Disease: Yes / No _______________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diabetes Yes / No High Blood Pressure Yes / No Chest Pain Yes / No

Arthritis Yes / No Rheumatic Fever/Heart Yes / No Colon Polyps Yes / No

Anemia Yes / No Gall Bladder Disorder Yes / No Stomach Ulcer Yes / No

Epilepsy Yes / No Difficulty Swallowing Yes / No Liver Disease Yes / No

History of Psychiatric Illness: Yes / No History of blood clotting / bleeding disorders: Yes / No History of Tuberculosis: Yes / No History of Human Immunodeficiency Virus (HIV): Yes / No History of Hepatitis: Yes / No Any previous difficulty with sedation or anesthesia: Yes / No

Surgical History (Include date(s) if known): _______________________________________________________________

__________________________________________________________________________________________________ __________________________________________________________________________________________________

Patient History 4/2004, rev: 08/2011, rev: 11/2018

Name of Medication Dosage Frequency Name of Medication Dosage Frequency

1) 9)

2) 10)

3) 11)

4) 12)

5) 13)

6) 14)

7) 15)

8) 16)

Drug / Item Reaction it causes

Cape Fear Center for Digestive Diseases, PA

Patient Name: __________________________________________ Date of Birth: _____/_____/_____

Patient History 4/2004, rev: 08/2011, rev: 11/2018

Family History: Father Mother P. Grandparents M. Grandparents Siblings Children

Colon Cancer

Colon polyps

Stomach Cancer

Pancreatic Cancer

Crohn’s or Colitis

Stomach Ulcer

Heart Disease

Stroke

Diabetes

Iron Storage Disease (Hemochromatosis)

OTHER: ___________________________________________________________________________________________ __________________________________________________________________________________________________

Tobacco Use (Please describe present and past): (Example: 1 pack daily for 25 years, but discontinued 3 years ago): __________________________________________________________________________________________________ Alcohol Use Yes/No (Amount/How often?) ___________________________________________________ Coffee/Tea/Sodas Yes/No (Amount/How often?) ____________________________________________________ Employment/Hobbies: _______________________________________________________________________________

Review of Systems (Your History) Change in bowel habits? Yes/No Comments: _________________________________________________ Diarrhea? Yes/No ___________________________________________________________ Constipation? Yes/No ___________________________________________________________ Red blood in your stools? Yes/No ___________________________________________________________ Black stools (like tar)? Yes/No ___________________________________________________________ Pain before or after stools? Yes/No ___________________________________________________________ Bloating / Distention? Yes/No ___________________________________________________________ Heartburn / Indigestion often? Yes/No ___________________________________________________________ Frequent nausea or vomiting? Yes/No ___________________________________________________________ Recently lost weight? Yes/No ___________________________________________________________ Recently gained weight? Yes/No ___________________________________________________________ Snore loudly / not sleep well? Yes/No ___________________________________________________________

Appetite? Good / Fair / None __________________________________________________

Women Only: Pregnant Yes / No Planning Pregnancy Yes / No Breastfeeding Yes / No Contraceptive Type: _____________________

Patient Signature/Date: ________________________ Physician Signature/Date: _________________________

Have you ever had any of these procedures? Date Findings

Colonoscopy Yes / No

Flexible Sigmoidoscopy Yes / No

Upper Endoscopy Yes / No

ERCP Yes / No

EUS Yes / No

CT scan of abdomen or GI tract (past 6 months) Yes / No

Ultrasound of abdomen or GI tract (past 6 months) Yes / No

MRI / MRCP Yes / No

CAPE FEAR CENTER FOR DIGESTIVE DISEASES, P.A.

Patient Name __________________________________________ DOB ____________________________

Financial Policy and Assignment of Benefits

The intent of this document is to inform you of the financial policy of Cape Fear Center for Digestive Diseases, P.A. We are

committed to providing you with the best possible care and service; therefore, your complete understanding of our financial

policy as it relates to your financial obligations is essential.

Payment is due in full at the time of service for all patients who have an insurance policy with which we have no contractual relationship. However, as a courtesy to our patients, we will file your claim with your insurance carrier. Delayed or non-

paid claims by your insurance carrier are not the responsibility of Cape Fear Center for Digestive Diseases, P.A. We accept cash, personal checks, money orders, or credit cards (MasterCard, Visa) as payment for services rendered. Should a credit payment result in an overpayment, the refund will be returned to the same card. Any credit due that is less than $25.00 will be refunded at the request of the patient. Otherwise, the credit will be applied to future services rendered.

A $35.00 returned check fee may be assessed to the account for each check returned for insufficient funds, stopped payment, or account closed.

All deductibles, copayments, and coinsurance are due at the time of service for any patient who has an insurance policy with which we have a contractual relationship. Any service that carrier deems is a non-covered service is the responsibility of the patient and will be payable in full within 30 days after receipt of your billing statement.

Any past due balances may be subject to additional collection fees, and we reserve the right to turn any patient over to collections if the account is in default of the payment obligation or compliance with this policy.

If you do not cancel an appointment with at least 48 hours notice, there may be an additional charge of $50.00 applied to your account within 10 days after the date of the missed appointment. Any procedure scheduled by your physician must be cancelled with 5 days prior to your appointment. A charge of $100.00 will be applied to your account within 10 days after the missed procedure. Multiple cancellations or missed appointments without prior notice may result in release from the practice by the physician.

Administrative charges may be assessed for furnishing copies of your medical records to other physicians, insurance carriers, attorneys or entities providing appropriately signed and legal release. If we are asked to participate in a deposition or to produce, with proper authorization, medical records for your insurance company or attorney, administrative charges may be assessed.

It is the policy of Cape Fear Center for Digestive Diseases, P.A. not to discuss a patient’s account information or medical record with anyone other than the patient, unless the patient gives prior written consent.

The physicians of Cape Fear Center for Digestive Diseases have a financial interest and ownership in Digestive Health

Endoscopy Center.

I agree to forever hold harmless Cape Fear Center for Digestive Diseases, P.A., their physicians and staff, for refusal to render

further services in the event I do not honor this financial agreement. I understand that for any service I do not pay in full at

the time service is rendered, I assign benefits for that claim to Cape Fear Center for Digestive Diseases, P.A. Having read and

fully understanding the above information, I authorize Cape Fear Center for Digestive Diseases, P.A. to submit appropriate

information to my insurance company for processing of my claim.

________________________________________________ ________________________

Patient’s Signature Date

_______________________________________________________________ ___________

Parent/Guardian Signature (if patient is a minor) Date

Financial Policy and Assignment of Benefits-English 2-11, Rev. 07-11, Rev.02-12, Rev. 10-12, Rev. 11-14

Clinic Form #02

Cape Fear Center for Digestive Diseases, PA

1880 Quiet Cove Fayetteville, NC 28304 910-323-2477 Consent to Treatment/HIPAA 05/2011, Rev. 07/2011, 2016

CONSENT TO TREATMENT

I am a patient at Cape Fear Center for Digestive Diseases, PA. (CFCDD, PA). By signing this form, I consent to be treated by the

providers of this practice.

My doctor needs more medical facts about my health. I, _____________________________________, date of birth ____________________ ask for and

allow Dr. _______________________ and staff to give me the needed medical treatment and services that he or she recommended.

I understand that treatment and services may include:

Lab tests,

Screening tests (tests that can find an illness earlier, before a person shows signs of having the disease),

Diagnostic tests (tests that show if a person has a certain illness or health problem), and

Routine exams.

I understand that no promises have been made to me about the results of any treatment or services.

_________________________________________________ ___________________________________________

Signature of Patient or Responsible Party Date

_________________________________________________ ___________________________________________

Witness Date

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

ACKNOWLEDGEMENT OF RECEIPT

I, ________________________________________, hereby acknowledge that CFCDD, PA has given me the opportunity to read a detailed notice

of their Privacy Practices. A copy is available in the clinic lobby, and on our website www.cfcdd.com, look under the For Patients tab.

Patient/Guarantor Signature* _____________________________________________ Date ______________________________________________ *If patient is a minor (under the age of 18), form must be signed by a parent or legal guardian.

If not signed, please provide a reason why the acknowledgment was not obtained.

____________________________________________________________________________________________________________________________________________

Witness _____________________________________________________________________ Date _____________________________________________ Staff Signature

CONSENT TO RELEASE INFORMATION

In the event I cannot be reached, I, ___________________________________________, give permission for a representative from

CFCDD, PA, to speak with family member(s) or companion(s) listed below regarding care or test results.

Name ___________________________________________________ Phone ________________________________________

Relationship ___________________________________________

Name ___________________________________________________ Phone ________________________________________

Relationship ___________________________________________

Is it OK to leave results or information on your voicemail/answering machine? Yes No

Is it OK to send results or information to you by mail? Yes No

Patient/Guarantor Signature* __________________________________________________ Date _____________________________________________

*If patient is a minor (under the age of 18), form must be signed by a parent or legal guardian.

ADVANCED DIRECTIVE 1. Do you have an Advanced Directive or Do Not Resuscitate Order (DNR)? Yes No

2. (If yes to #1) I will supply a copy of my Advance Directive in case of hospital transfer. Yes No

3. I understand that CFCDD does not honor Advance Directives. Yes No

4. I understand that in the event of an accidental needle stick, I will be required to have blood drawn for testing. Yes No

Signed ___________________________________________________ Date ________________________________________