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WELCOME

Gastroenterology Consultants of South Jersey
Amherst Commons, Building A, Suite 2
693 Main Street, Lumberton, New Jersey
Telephone: (609) 265-1700  Visit us Online: www.GCSJ.org

1- PATIENT INFORMATION 2- INSURANCE
Date:
SS/HIC/Patient ID#:
PATIENT NAME:


Address:
City:      
State:     
Zip:        
Email:
Sex: M F      Age: Birthdate:
 
        Married Widowed Single Minor
        Separated Divorced Partnered for years.
Occupation: 
Patient Employer/School:
    
Employer/School Address:
    
    
Employer/School Phone:
Spouse's Name:
               Birthdate:
               SS#:        
Spouse's Employer:
Who may we thank for referring you?

Who is responsible for this account?

Relationship to Patient:
Insurance Co.:
Group #:
Is patient covered by additional insurance? Yes No.
Subscriber's Name:
Birthdate: SS#:
Relationship to Patient:
Insurance Co.:
Group #:

INSURANCE ASSIGNMENT AND RELEASE
I certify that I have insurance coverage with (Name of Insurance Company(ies) and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurance.  I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.  This consent will end when my current treatment plan is completed or one year from the date signed below.

MEDICARE/MEDIGAP AUTHORIZATION
I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made either to me or on my behalf to (Name of Doctor or Clinic) for any services furnished to me by that provider.

To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits for related services.

_______________________________________________________
Signature of Beneficiary, Guardian, or Personal Representative

Please print/type name of Beneficiary, Guardian or Personal Representative:

Date:
Relationship to Beneficiary:

3- PHONE NUMBERS

Home: Cell:
Best time and place to reach you:
 
IN CASE OF EMERGENCY -- CONTACT:
Name:
Relationship to Patient:
Home Phone:
Work Phone: 

4- FAMILY HISTORY

Date of last physical examination:
What is your reason for visit?

 FATHER
       Alive: Deceased:
 Present Health or cause of death:
 MOTHER
       Alive: Deceased:
 Present Health or cause of death:
SPOUSE
       Alive: Deceased:
 Present Health or cause of death:
 BROTHERS 
# Alive: # Deceased:  Health:   
Cause of Death:
 SISTERS
# Alive: # Deceased:  Health:  
Cause of Death:
 CHILDREN
# Alive: # Deceased:  Health:  
Cause of Death:
CHECK ILLNESSES WHICH HAVE OCCURRED IN ANY OF YOUR BLOOD RELATIVES:
Diabetes Cancer Bleeding tendency Kidney disease Tuberculosis Heart disease Stroke High blood pressure
Nervous illness Allergy Other and/or Explanation: 
*FOR 2-PAGE PRINTING - PLEASE STATE PATIENT NAME AGAIN

Current Date:   SS/HIC/Patient ID#:
PATIENT NAME: 
                          

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Copyright 2005 Gastroenterology Consultants of South Jersey, P.C. All Rights Reserved.

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