Patient Registration Form

Copies of insurance cards are required for proper filing. If cards are unavailable, then we request you bring copies back as soon as possible. You will be required to sign a waiver before services are rendered if you do not present your insurance cards. You will be held responsible for the services.
Your insurance company may not cover screening services: therefore, you may be responsible for payment. Even though your physician recommends tests to you, please be aware that your insurance company may not cover the cost of screening evaluation or testing. Your insurance company may not cover other certain services. Be sure you call your insurance company to verify your benefits for screening/routine procedures and outpatient surgery prior to any test performed. As a patient, this is your responsibility.
If you are sent out of our office for a procedure, test, x-ray or lab work, there will be additional charges from that particular facility which will be billed separately. If a specimen is taken during your in office procedure it will be sent to NorthEast Medical Center for testing and billed separately by NEMC.

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the release of any medical information necessary to process this claim. Payment of medical benefits is requested to undersigned physician or supplier for services rendered.

ACKNOWLEDGEMENT: I acknowledge that I have received the Notice of Privacy Practices or a personal representative has appeared before me. Please describe personal representative’s relationship to the patient if it applies.

I understand and agree to all the above statements.

MEDICARE PATIENTS ONLY: I request that payment of authorized Medicare benefits be made either to me or on my behalf to Cabarrus Gastroenterology Associates for any services furnished to me by that physician/supplier. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits or the benefits payable for related services.
I request that payment of authorized Medigap benefits be made on my behalf to Cabarrus Gastroenterology Associates for any services furnished to me by that physician/supplier. I authorize any holder of medical information about me to release to supplemental policy any information needed to determine these benefits.

ACKNOWLEDGEMENT: I acknowledge that I have received the Notice of Privacy Practices or a personal representative has appeared before me. Please describe personal representative’s relationship to the patient if it applies.

I understand and agree to all the above statements.