EGD Colonoscopy Colonoscopy prep Flexible Sigmoidoscopy ERCP Liver Biopsy Capsule endoscopy Gerd & Ulcer treatment IBS treatment IBD treatment Hepatitis C treatment Download pdf from welcome Package PATIENT INFORMATION Name Email Sex Address Date of Birth Social Security # City / State Marital Status Single Married Divorced Phone Referring Physician Primary Physician   PATIENT EMPLOYMENT Employment Employed Retired Other Employer Phone Contacts     GUARANTOR Guaranter Same as patient Name Address Date of Birth Social Security # Phone Employer City / State   Primary Insurance Primary Insurance Same as patient Same as Guaranter other Insured Party Insured Phone Company Relationship to Patient: Social Security # Insured ID   SECONDARY INSURANCE Secondary Insurance Same as patient Same as Guaranter other Insured Party Insured Phone Date Of Birth Company       I hereby authorize direct payment of surgical/medical benefits to GI Consultants, LLC for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance.   I hereby authorize GI Consultants, LLC to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.   I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be valid as the original.     Powered by: www.dotsandcoms.us Copyright © 2008, GI Consultants | All Rights Reserved