A d v a n c e d
S u r g e r y
____________________________________________________
GLENN L. SANDLER, M.D.
______________________________________________
•
CRAIG P. COLLIVER, M.D.
Dear Patient:
Your appointment is scheduled for _____________________________________________________________.
____ Rockville Office: 9707 Medical Center Drive, Suite 320 Rockville, MD 20850
____Germantown: 19735 Germantown Road, Suite 255 Germantown, MD 20874
** Please plan to arrive 20 minutes prior to your scheduled appointment time.
We request updated forms be completed when your information has changed or once a year.
Please be sure to bring all items that apply:
 Completed Forms that are enclosed
 Diagnostic Imaging and/or Procedure Reports WITH corresponding written reports(s), if any. Ex. Mammo/US,
Colonoscopy/EGD Procedure Reports w/ Color Photos. (You will need to pick up these items from the facility
where you had them performed.)
 Lab results, if any. (You will need to obtain a copy of the results from the physician who ordered them.)
 Insurance Card(s)
 Current Drivers License or Photo ID
 Referral from your Primary Care Physician (If required-you may need to call your insurance company if you
are unsure.)
 Method of payment: cash, check, Visa, MasterCard, Discover (If your insurance plan requires a co-payment.)
Please note a $25 charge will be applied for ALL missed appointments and/or
appointments cancelled without a 24 hour business day prior notice.
If you have any questions please contact our office at 301.251.4128 Monday-Friday from 8:30am-4:30pm.
Sincerely,
Advanced Surgery, PC
9707 MEDICAL CENTER DRIVE, SUITE 320 * ROCKVILLE, MD * 20850
P H O N E : ( 3 0 1 ) 2 5 1 - 4 1 2 8▪ F A X : ( 3 0 1 ) 7 3
www.advancedsurgery.net
8-1593
ADVANCED
GLENN
PAGE
SANDLER
SURGERY, PC
MD
AND
CRAIG
COLLIVER
MD
1
Today’s Date:
(Please Print)
For office Use: GS
CC
PATIENT INFORMATION
Primary Care Physician or Group:
Referring Physician:
First Name:
Mr.
MI:
Mrs.
Miss
Ms.
Last Name:
Sr.
Jr.
Preferred Name:
III
Street address:
City:
County:
Street address 2:
State:
ZIP Code:
Home no.: (
)
Work no.: (
)
Sex:
Race:
M
Cell no: (
Email:
Chinese
Filipino
Occupation:
Hispanic
Married
Divorced
Native
American
Indian
Age:
Social Security #:
@
Marital Status: Single
F
Black
Birth date:
)
Separated
Native
Hawaiian
Employer:
Other
Widowed
Partnered
Oriental/Asian
Status: FT
PT
Pacific
Islander
Ret
Tmp
Employer Address:
City:
County:
Employer Address 2:
State:
ZIP Code:
INSURANCE INFORMATION
Is this visit related to a work injury
(Workman’s Compensation)
YES
HMO
PPO
POS
Open Access
Telephone #:
Street address:
City:
Patient’s relationship to subscriber:
Other:
(Please give your insurance cards to the receptionist.)
NO
Primary Insurance Name
Subscriber’s name: (If different from above)
Caucasian
Subscriber’s S.S. no.:
Self
Birth date:
Spouse
Child
State:
ZIP:
Policy no.:
Other
Subscribers Place of Employment:
Group no.:
Sex:
M
F
Tel Number:
Secondary I nsurance I nform ation
Secondary Insurance Name
Telephone #:
Street address:
HMO
City:
Subscriber’s name: (If different from above)
Patient’s relationship to subscriber:
Subscriber’s S.S. no.:
Self
Birth date:
Spouse
Subscribers Place of Employment:
Child
PPO
State:
Open Access
ZIP:
Policy no.:
Other
POS
Group no.:
Sex:
M
F
Tel Number:
WHO ARE WE AUTHORIZED TO COMMUNICATE WITH ON YOUR BEHALF?
Name of person(s) to call in case of emergency, receive medical info, make or
change appointments, receive results, etc.
YES
DO NOT
Relationship to patient:
Cell phone no.:
Work/Home
Leave a message on my answering machine/voice mail/email or with anyone in my household who answers the phone.
ADVANCED SURGERY, PC
GLENN
SANDLER
MD
AND
CRAIG
COLLIVER
MD
REGISTRATION FORM
Page 2
NOTICE OF PRIVACY PRACTICES/FINANCIAL TERMS AND CONDITIONS
By signing below I am verifying that: I have received a copy of ADVANCED SURGERY, PC ‘s “NOTICE OF PRIVACY PRACTICES”,
that I have had the opportunity to review the notice and ask any questions regarding the information provided within the notice,
that I understand the information contained within the NOTICE/DOCUMENT and that I may obtain a copy of the document upon
request at any time.
We are committed to providing you with the best possible care and service. If you have medical insurance, we are happy to assist
you to receive your maximum allowable benefits. In order to achieve these goals, you will need to remit all relevant insurance
policy information to the provider at the time of service.
Please understand:
1. Your insurance is a contract between you and the insurance company. 2. You are responsible for whatever portion your
insurance deems as your responsibility. 3. Not all services are a covered benefit in all contracts. Some insurance companies
arbitrarily select certain services they will not cover. These charges are your responsibility.
Unless otherwise agreed upon by the provider, payment for services is due at the time services are rendered. We accept cash,
checks, MasterCard, or Visa. We will be happy to help you process and/or directly submit your insurance claim-form for
reimbursement.
We will gladly discuss your proposed treatments and charges, and will answer any questions relating to your services.
A copy of this form may be used in place of the original for proof of signature for insurance companies.
Returned checks will be subject to a $25.00 bad check fee. A $25.00 charge will also be applied for missed appointments and
appointments cancelled without 24 hours advance notice. In the unfortunate event collection procedures are required to collect an
outstanding account balance, the patient shall be responsible for the collection fee equal to 35% of any past due balance.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I
understand that I am financially responsible for any balance. I also authorize Advanced Surgery, PC, or insurance company to
release any information required to process my claims.
By my signature, I indicate that I have read, understand and do hereby accept the terms of this agreement.
Patient/Guardian signature
Date
MEDICARE PATIENTS ONLY
I request that payment of authorized Medicare benefits to be made either to me or on my behalf to Advanced Surgery, PC, for
any services furnished by that physician or 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 payable for related
services.
I request that payment of authorized Medigap benefits be made either to me or on my behalf to Advanced Surgery, PC., for any
services furnished by that physician. 11 authorize any holder of medical information about me to release to the above named
Medigap insurer, any information needed to determine these benefits payable for related services.
Patient/Guardian signature
Date
Advanced Surgery, PC
Dr. Glenn Sandler and Dr. Craig Colliver
HEALTH HISTORY QUESTIONNAIRE
Date:_____________________________________
All questions contained in this questionnaire are strictly confidential and will become part of your medical records
Name:
M
(Last, First, M.I.)
Marital status:
Single
Primary Care Physicians:
Partnered
Married
F
DOB:
Separated
Referring Physicians:
Age:
Divorced
Widowed
PLEASE DESCRIBE THE REASON FOR YOUR VISIT TODAY
PLEASE LIST YOUR MEDICATIONS AND DOSAGES (Please attach additional sheet if necessary)
Strength (MG)
Medication Name
Times per day
ALLERGIES TO MEDICATIONS
Referring Physician
None
Name of Drug
Reaction You Had
Are you allergic or sensitive to LATEX?
Yes
No
PAST MEDICAL HISTORY (Please check all that apply)
None
Colitis
Heart murmur
MI/Heart attack
Rheumatoid arthritis
ADD
Colon cancer
Hepatitis A
Migraine
Seizure disorder
Alzheimer's/Dementia
Congestive Heart Failure
Hepatitis B
Mitral valve prolapse
Sleep apnea
Anemia
COPD
Hepatitis C
Multiple sclerosis
Stomach cancer
Herpes
Osteoarthritis
Stomach ulcer
Angina
Coronary Artery Disease
Anxiety
Crohn's disease
Hiatal hernia
Osteoporosis
SVT
Aortic aneurysm
CVA/Stroke
High blood pressure
Ovarian cancer
Thyroid cancer
Arthritis
Depression
High cholesterol
Ovarian cysts
Urinary infection-chronic
Asthma
Diabetes Type 1
HIV/Aids
Parkinson's disease
Ulcerative colitis
Atrial fibrillation
Diabetes Type 2
Hyperthyroidism
Presently pregnant
Urinary incontinence
Blood clotting issues
Diverticulitis
Hypothyroidism
Prostate cancer
Use Coumadin
Bowel obstruction
Endometriosis
Irritable bowel syndrome
Prostate enlarged
Use Plavix
Breast cancer
Fibromyalgia
Kidney stones
Poor circulation
Use aspirin
Cervical cancer
GI Bleed
Low platelets
Pulmonary embolism
Use other anticoagulant
Cirrhosis
H. pylori
Lupus
Reaction to anesthesia
Other___________________
Clots in legs
Heartburn/Reflux
Melanoma
Renal failure chronic
Health History page 1
Advanced Surgery, PC
Dr Glenn Sandler and Dr. Craig Colliver
Health History Questionnaire
(Continued)
Name: ________________________________________
Date:__________________________________
PAST SURGICAL HISTORY (Please check all that apply)
None
Cataract extraction
Kidney removed
Sinus surgery
Abdominal surgery exploratory
Colon resection
Knee arthroscopy
Small bowel resection
Abdominoplasty/tummy tuck
Colonoscopy
Knee replacement
Splenectomy
Angioplasty/stent
Dental surgery
Lumpectomy
Stomach(part of removed)
Aortic valve replacement
Ectopic pregnancy
Lung resection
Thyroidectomy
Appendectomy
Femoral hernia
Mastectomy
Axillary lymph node dissection
Gallbladder removed
Mitral valve replacement
Back surgery
Gastric bypass
Ovarian cyst removal
Bladder surgery
Hand/Finger surgery
Pacemaker
TURBT
Brain surgery
Heart bypass
Pancreatic surgery
TUR
Breast biopsy
Hemorrhoidectomy
Pilonidal cyst
Umbilical hernia
Tonsillectomy
Tooth extraction
Tubal ligation
Breast implants
Hip replacement
Prostate removal
UPPP
Breast reduction
Hysterectomy w/tubes & ovaries
Remove tubes/ovaries only
Valve replacement
C section
Hysterectomy w/o tubes & ovaries
Rotator cuff repair
Vasectomy
Carotid endarterectomy
Incisional hernia
Sentinel lymph node biopsy
Carpal tunnel
Inguinal hernia
Shoulder surgery
Other
____________________
Family History of (Please select all that apply)
None
Unknown
Please indicate, next to the condition, the family member who has or had the disease using the abbreviations below:
M=Mother,
F=Father,
S-Sister, B=Brother, MGF=Maternal Grandfather, PGF=Paternal Grandfather, MGM=Maternal Grandmother
PGM=Paternal Grandmother,
Bladder cancer
PU=Paternal Uncle, MU=Maternal Uncle, PA=Paternal Aunt, MA=Maternal Aunt
________
Breast cancer
Melanoma
________
Colon cancer
Ovarian cancer
________
Crohn's disease
Gastric cancer
Kidney cancer
Prostate cancer
________
________
________
Reaction to anesthesia
________
Stomach cancer
________
Thyroid cancer
Liver cancer
________
Ulcerative colitis
Lung cancer
________
Uterine cancer
Lymphoma
________
Pancreatic cancer
________
Head and Neck cancer
________
________
________
________
________
________
________
Other ______________________________________________________
Social History (Please check each column)
Marital Status:
Employment status: Tobacco (choose one)
Do you drink alcohol?
Single
Employed
Current every day smoker
Married
Not employed
Current some day smoker
Divorced
Self employed
Yes
No
If yes, what kind?
Cigarettes
Amount____ pks/day _______________________
Separated
Stay at home mom
Cigars
Amount____
#/week # drinks per day? ________
Widowed
Retired
Chew
Amount____
#/day
Partnered
Student
Former smoker: Year quit ______
Never smoker
Health History page 2
Advanced Surgery, PC
Dr. Glenn Sandler and Dr. Craig Colliver
Health History Questionnaire
(Continued)
Name: _________________________________________
Date:________________________________________
Height and Weight
Height: _______________________
Weight: __________________
Please check off all that apply for each body system
General complaints of:
Skin
Nervous System
No Complaints of this type
No Complaints of this type
No Complaints of this type
Fever
Rash
Difficulty with Memory
Headaches
Chills
Itching
Difficulty with Speech
Dizziness
Sweats
Dryness
Difficulty Walking
Lack of Appetite
Yellowing Skin
Fainting
Weight Loss
Changes in Hair
Paralysis
Weight Gain
Changes in Nails
Numbness
Fatigue
Changes in Moles/Lesions
Seizures
Unable to sleep
New Skin Lesions
Tremors
Weakness
Cardiac
Breathing
Hematologic
No Complaints of this type
No Complaints of this type
No Complaints of this type
Chest Pains
Cough
Bruise Easily
Heart Racing
Shortness of Breath in general
Bleed Easily
Shortness of Breath while lying down
Coughing up Blood
Blood Clots
Shortness of Breath with exertion
Wheezing
Enlarged Lymph Nodes
Swelling in legs
Painful Breathing
Bleeding Gums
Gastrointestinal
Psychological
No Complaints of this type
No complaints of
Genitourinary
Painful Swallowing
Heartburn
Nosebleeds
Men
this type
Women
Depression
Abdominal Pain
No Complaints of this type
No Complaints of this type
Anxiety
Nausea
Painful Urination
Vaginal Discharge
Hallucinations
Vomiting
Bloody Urine
Urine leakage
Paranoia
Vomiting Blood
Penile Discharge
Painful Urination
Phobias
Diarrhea
Frequent Urination
Bloody Urine
Constipation
Hesitancy in Urination
Frequent Urination
Black Stools
Frequent Night Urination
Abnormal Vaginal Bleeding
Bloody Stools
Urine Leakage
Pelvic Pain
Gas/Bloating
Erectile Dysfunction
Change in Bowel Habit
Difficulty Swallowing
Yellow eyes or skin
Health History page 3
Advanced Surgery, PC
Dr. Glenn Sandler and Dr. Craig Colliver
Health History Questionnaire
(Continued)
Name: _________________________________________
Date:_____________________________________
Please check off all that apply for each body system
Vascular
Muscular/Skeletal
Endocrine
No Complaints of this type
No Complaints of this type
No Complaints of this type
Blue Fingers/Toes
Joint Pain
Intolerance to Cold
Swelling in Extremities
Joint Swelling
Intolerance to Heat
Varicose Veins
Back Pain
Excessive Thirst
Pain in Legs with Walking
Muscle Weakness
Excessive Hunger
Resting leg Pain
Muscle Shrinkage
Excessive Urination
Muscle Cramps
Women only
Age at onset of menstruation: ___________________________
Number of pregnancies:__________
Are you currently breastfeeding?
Date of last menstruation:___________________________
Number of live births:____________
Yes
Age at first live birth:__________
No
Have you ever taken birth control pills or hormone therapy?
Yes
No
If yes, for how long? _____________________
Please list any physicians to whom you would like a report of your treatment sent: (write name of physician)
OB/Gyn:
Gastroenterologist:
Cardiologist:
Dermatologist:
Other:
Health History page 4
DISCLOSURE OF PHYSICIAN OWNERSHIP
NOTICE TO PATIENTS
Please carefully review the information contained in this notice.
1.
Glenn L. Sandler, MD and Craig P. Colliver are owners of Surgery Center of Rockville,
L.L.C.
2.
You have the right to choose the provider of your health care services. Therefore, you
have the option to use a health care facility other than Surgery Center of Rockville,
L.L.C.
3.
You will not be treated differently by your physician if you choose to obtain health care
services at a facility other than Surgery Center of Rockville, L.L.C.
If you have any questions concerning this notice, please feel free to ask your physician or
any representative of Surgery Center of Rockville, L.L.C. We welcome you as a patient and
value our relationship with you.
By signing this Disclosure of Physician Ownership, you acknowledge that you have read
and understand the foregoing notice and hereby understand that your physician has an ownership
interest in Surgery Center of Rockville, L.L.C.
______________________________
Signature of Patient
_______________________________
Signature of Parent or Guardian
(if applicable)
______________________________
Type or Print Name of Patient
_______________________________
Type or Print Name of Parent or Guardian
(if applicable)
Dated:_________________________
Advanced Surgery, PC
Dr. Glenn L. Sandler and Dr. Craig P. Colliver
NOTICE OF PRIVACY PRACTICES
UNDERSTANDING YOUR HEALTH RECORD & INFORMATION: Each time you visit a hospital, physician, or other healthcare
provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment
and a plan for future care or treatment. This information often referred to as your health or medical record, serves as a basis for planning
your care and treatment and serves as a means of communication among the many health professionals who contribute to your care.
Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who,
what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to
others.
YOUR HEALTH INFORMATION RIGHTS: Unless otherwise required by law, your health record is the physical property of the
healthcare practitioner or facility that compiled it; the information belongs to you. You have the right to request a restriction on certain uses
and disclosures of your information, and request amendments to your health record. This includes the right to obtain a paper copy of the
notice of information practices upon request, inspect, and obtain a copy of your health record. You may obtain an accounting of disclosures
of your health information, request communications of your health information by alternative means or at alternative locations, revoke your
authorization to use or disclose health information except to the extent that action has already been taken.
OUR RESPONSIBILITIES: This organization is required to maintain the privacy of your health information, and in addition, provide you
with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. This organization
must abide by the terms of this notice; notify you if we are unable to agree to a requested restriction, accommodate reasonable requests you
may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices
and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we
will mail a revised notice to the address you have provided. If we maintain a Website that provides information about our customer services
or benefits, we will post our new notice on that website. We will not use or disclose your health information without your authorization,
except as described in this notice. A hard copy of this notice will be provided to you.
EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH OPERATIONS
We will use your health information for treatment. For example; Information obtained by a healthcare practitioner will be recorded in
your record and used to determine the course of treatment that should
work best for you. By way of example, your physician will document
in your record their expectations of the members of your healthcare
team. Members of your healthcare team will then record the actions
they took and their observations. We will also provide your other
practitioners with copies of various reports that should assist them in
treating you.
Communication with family: Health professionals, using their best
judgment, may disclose to a family member, other relative, close
personal friends or any other person you identify, health information relevant to that person’s involvement in your care or payment
related to your care.
We will use your health information for payment. For example: A bill
may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as
your diagnosis, procedures, and supplies used.
Food and Drug Administration (FDA): As required by law, we may
disclose to the FDA health information relative to adverse events
with respect to food, supplements, product and product defects, or
post marketing surveillance information to enable product recalls,
repairs, or replacement.
We will use your health information for regular health operations. For
example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use
information in your health record to assess the care and outcomes in
your case and others like it. This information will then be used in an
effort to continually improve the quality and effectiveness of the
healthcare and service we provide.
Business Associates: There may be some services provided in our
organization through contracts with Business Associates. Examples
include physician services in the emergency department and radiology,
certain laboratory tests, and IT service providers that have access to
our data. When these services are contracted, we may disclose some
or all of your health information to our Business Associate so they can
perform the job we’ve asked them to do. To protect your health information, however, we require the Business Associate to appropriately
safeguard your information.
Notification: We may use or disclose information to notify or assist in
notifying a family member, personal representative, or another person
responsible for your care, your location, and general condition.
Marketing: We may contact you to provide appointment reminders
or information about treatment alternatives or other health-related
benefits and services that may be of interest to you.
Workers compensation: We may disclose health information to the
extent authorized by and to the extent necessary to comply with laws
relating to workers compensation or other similar programs
established by law.
Public Health: As required by law, we may disclose your health
information to public health or legal authorities charged with tracking births and deaths, as well as with preventing or controlling
disease, injury, or disability.
Correctional Institutions: Should you be an inmate of a correctional
institution, we may disclose to the institution or agents thereof health
information necessary for your health and the health and safety of
other individuals. An inmate does not have the right to this Notice.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid
subpoena.
Effective Date: This notice will be effective from April 14, 2003.
A d v a n c e d
Surgery,
_______________________________________
GLENN L. SANDLER, MD, FACS
PC
_______________________________________
•
CRAIG P. COLLIVER, MD, FACS
Financial Policy
Deductibles/Co-Insurances for Surgery:
Advanced Surgery requires you to pay any in-network or out of network deductibles and/or co-insurance
portions prior to your scheduled surgery. Our billing department will contact you with an estimated
amount. This is only an estimate; after we receive payment from your insurance carrier we will either
bill or refund you according to your insurance explanation of benefits. We accept Visa, MasterCard,
Discover or personal checks. If paying by check, we must receive payment no later than 3 days prior to
your scheduled surgery.
Please note: The fees collected and billed to your insurance carrier are for your surgical procedures
performed by Dr. Sandler or Dr. Colliver. This does not included any fees you may owe to the Hospital,
Ambulatory Surgical Center, Anesthesia, Pathology, Radiology or Laboratory Services, which are
billed separately from our surgeon’s fees. We do not bill or collect deductibles and/or co-insurances for
any of the above mentioned facilities. If you have any questions, please contact those facilities directly
regarding any insurance questions you may have.
Pre-Authorization for Surgery:
Our office will contact your insurance company to obtain preauthorization for your procedure. However,
this is not a guarantee that your insurance company will pay for your surgery. Patients are responsible
for their benefits, coverage and payment for all services rendered by Advanced Surgery. We encourage
our patients to take this opportunity to understand their personal insurance benefits. If you have any
questions, you should contact your insurance carrier, employer HR Department or insurance broker to
verify your benefits, eligibility and coverage.
Deductibles/Co-Insurances for Office Visits:
Advanced Surgery requires you to pay any in-network or out of network deductibles, co-pays and/or coinsurance portions at the time of your office visit.
Updated 7/9/2009
9 7 0 7 M E D I C A L C E N T E R D R I V E , S U I T E▪ R
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www.advancedsurgery.net
8-1593
a d v a n c e d
s u r g e r y
GLENN L. SANDLER, MD
•
CRAIG P. COLLIVER, MD
Directions
Rockville
9707 Medical Center Drive, Suite 320, Rockville, MD 20850
P: 301-251-4128
F: 301-738-1593
From points north or south:
Take I-270
Take Exit 8 to Shady Grove Road headed west
Follow signs to the Hospital
Turn right onto Medical Center Way (at sign for Shady Grove Hospital)
Turn right at stop sign onto Medical Center Drive
Make your first left into our parking lot (Sona Bank building)
Germantown
19735 Germantown Road, Suite 255, Germantown, MD 20874
P: 301-251-4128
F: 301-738-1593
From points north of Germantown:
Take I-270 S
Take Exit 15A-B (Germantown Road)
Bear right onto Germantown Road
At Middlebrook Road, make a U-turn
19735 Germantown Road (Shady Grove Adventist Building) is on the right
Turn into the first driveway and park in the rear
From points south of Germantown:
Take I-270 N
Take Exit 13B/Middlebrook Road
Turn right onto Germantown Road (MD 118 North)
19735 Germantown Road (Shady Grove Adventist Building) is on the right
Turn into the first driveway and park in the rear
9 7 0 7 M E D I C A L C E N T E R D R I V E , S U I T E 3 2 0▪ R O C K V I L L E , M D ▪
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WWW.ADVANCEDSURGERY.NET
8-1593
20850