Patient Forms
New Patient Registration
Complete all three forms below, then print them or save them as a PDF to bring to your appointment. You can also print them blank and complete them by hand. Your information stays on your device — nothing is submitted or stored online.
Form 1 of 3 — New Patient Registration
Patient Information
Emergency Contact
Pharmacy Information
Insurance
Acknowledgment
I certify the above information is accurate to the best of my knowledge.
If you prefer, leave the signature blank and sign by hand after printing.
Form 2 of 3 — Authorization & Assignment of Benefits
Medicare Patients
I request that payment of authorized Medicare benefits be made on my behalf to Advanced Gastroenterology Center, PC for services furnished to me by that practice. 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 hereby authorize Medicare to furnish to the above named practice/physician any information regarding my Medicare claim under Title XVIII of the Social Security Act.
All Patients
I hereby authorize Advanced Gastroenterology Center, PC to apply for benefits on my behalf for covered services rendered by this practice/physician or by physician’s order. I request that payment from my insurance company be made directly to Advanced Gastroenterology Center, PC. I authorize the release of any medical information necessary to process this claim. I permit a copy of this assignment to be used in place of the original. This assignment will remain effective until revoked by me in writing.
I understand I am financially responsible for any balance allowed by my insurance carrier.
Leave the signature blank to sign by hand after printing.
Form 3 of 3 — Designation of Disclosure
I. Preferred Contact Method (check all that apply)
Select how we may reach you, and how much detail we may leave in a message.
II. Designated Relatives, Friends & Caregivers
I agree that Advanced Gastroenterology Center, PC may disclose health information relevant to a family member, close friend, or other caregiver involved with my care or payment, limited to what is relevant to that person’s involvement. I understand I am not required to list anyone, and may update this list at any time in writing.
Acknowledgement of Privacy Practices Notice
I acknowledge that I have received a copy of Advanced Gastroenterology Center, PC’s Notice of Privacy Practices, and that Advanced Gastroenterology Center, PC may use and disclose my health information as described in the Notice.
Leave the signature blank to sign by hand after printing.