OAC FORM (Step 1)

Gastrointestinal Associates, Inc.

Open Access Colonoscopy Questionnaire

Gastrointestinal Associates has developed a program which allows healthy individuals to schedule screening colonoscopy without the need for an office visit before the procedure.

EVERY QUESTION MUST BE ANSWERED OR WE WILL NOT BE ABLE TO SCHEDULE AN OPEN ACCESS COLONOSCOPY. Be advised that a Nurse from our office will review, and depending upon the answers, you may need to have an Office Visit prior to the Colonoscopy. Someone from our office will contact you.




  1. Open Access Colonoscopy at our institution is approved for patients age 45 to 70 in good health.



    Those who desire colon cancer screening below age 45 or above age 70 are encouraged to schedule an office visit to determine if screening is medically appropriate.




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A response to all questions is required in order to move forward with the submission

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Patient Statement for Open Access Colonoscopy:

I have reviewed the Open Access Colonoscopy Questionnaire and have answered all questions truthfully to the best of my knowledge.

  • Open Access Colonoscopy is designed to allow healthy, age appropriate patients to have a screening colonoscopy without an office visit. The Questionnaire that I have completed will be carefully reviewed and I may be called for points of clarification. For my safety, depending on the answers provided, I understand I may be scheduled directly for a Screening Colonoscopy or if I do not meet open access criteria, an office visit will be scheduled.
  • I certify that I have answered all questions correctly and completely. I understand that answering any questions incorrectly may impact my health.
  • I understand that by choosing to pursue Open Access Colonoscopy I have not, nor during this process will I have, a GI consultation. I understand that I have the choice to make an appointment for an office visit to discuss colonoscopy and the risk, benefits and alternatives and have declined to do so. I also understand that I will require a separate office visit to address any GI complaints I might have.
  • If I am scheduled directly for a Screening Colonoscopy I will be sent information by mail regarding preparation for the procedure, the procedure itself, and post-procedure concerns. I will read the information provided and make sure that I understand and will be able to comply with the instructions given.
  • I understand that, while not likely, there are risks involved with colonoscopy as with any medical procedure. These risks are outlined in the information that I have received. I have reviewed this information to my complete satisfaction and I understand the risks and the benefits of colonoscopy.
  • Should I have any changes in my health status or insurance after being scheduled, or any questions about the information I receive by mail I will call the office at 267-620-1100.
  • I understand that I must have someone drive me to the procedure and wait in the unit to drive me home. Without a driver in attendance the procedure will be cancelled.



Insurance Coverage

Please provide the details of the insurance you anticipate that you will use for this procedure. Please include all information, including plan name, that is noted on your card.







Please note: If your insurance information changes after you are scheduled but before the procedure, it is imperative that you call our office to alert us to avoid potentially charges.

 

 

       

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE
OF HEALTH INFORMATION






The above party may disclose this health information to the following recipient:

Gastrointestinal Associates, Inc.
1095 Rydal Road, Suite 100
Jenkintown, PA 19046
Ph: 267.620.1100
Fax: 215.572.1279

I understand that this authorization will remain in effect until the provider fulfills this request.

I understand that I may revoke this authorization by sending notification, in writing, to the following:

 

Alfreda Rawlings, Privacy Officer
1095 Rydal Road, Suite 100
Jenkintown, PA 19046