8530 West Sunset Roa d, Suite 230,
Las Vegas, NV 89113
www.neva da gastro.com
info@nevada gastro.com
office 702-483-4483
fax 702-410-6670
Dear Pa tient:
Welcome to our prac tic e! We rea lize tha t your time is va luab le, and we w ill make
every effort to see you at your sc hed uled app ointme nt time . Plea se a ssist us b y ma king
sure tha t you a rrive for your a pp ointme nt on time with your c om p leted pap erwo rk.
Ple a se print the a tta c hed forms a nd c om p lete a ll the req uested informa tion prior to
your offic e visit.
o Patient Registration & Medical History
Ple ase bring your insuranc e c ard and ID.
o Office & Financial Policy
o Notice of Privacy Policy
o Medical Records Release & Request Forms
We are humbled with the trust you place in us and will honor that trust through
comprehensive and compassionate services you deserve. We appreciate the
opp ortunity to serve you and your family for many years to com e.
Thank you.
Tarek Ammar, M.D., Gary Chen, M.D., Vijay Jayara man, M.D., Andrew Kim, M.D.,
John Ryan, M.D., Christian Stone, M.D., M.P.H.
rev.2015-10
PATIENT REGISTRATION
8530 West Sunset Roa d, Suite 230, Las Vegas, NV 89113
ww w.nevad ag astro.c om
conta ct@neva dag astro.com
offic e 702-483-4483 fax702-410-6670
PATIENT INFORMATION
o
o
patient name: LAST,FIRST
address: STREET
phone: HOME
CITY
CELL
DOB
o
o
o
o
Male
Female
STATE
Single
Married
Divorced
Widowed
ZIP
email
WORK
driver’s license
SSN
RACE:
preferred spoken language
o
o
o
o
o
White
Bla ck
Asian
Latino
Other
EMPLOYER INFORMATION
Employer
address:
phone
STREET
CITY
STATE
ZIP
occupation
INSUREDPERSON
(if not patient)
EMERGENCY
(not at
name: LAST, FIRST
relation to patient
SSN
DOB
phone
driver’s license
name: LAST, FIRST
relation to patient
phone
same address)
address:
INSURANCE INFORMATION
AUTHORIZATI
ON TO RELEASE
INFORMATION &
ASSIGNMENT BENEFITS
STREET
CITY
STATE
#1 PRIMARY INSURANCE CO.
ID#
#2 SECONDARY INSURANCE CO.
ID#
ZIP
I authorize the release of any medic al inform ation necessary to proc ess this claim. I permit a
c opy of this authorization to be used in plac e of the original.
SIGNATURE
DATE
I hereby authorize CDIN to a p ply for benefits on my behalf for c overed servic es rendered by the
medic al providers that belong to CDIN. I request that p ayment from my insuranc e c omp any be
ma de directly to CDIN (or to the p arty who a c cepts assi gnment). I fully certify that the information I
have reported with regard to my insuranc e c overage is c orrect. I permit a c opy of this
authorization to be used in pla ce of the original. Either my insurance c om pany or I m ay revoke this
authorization at any time in writing.
SIGNATURE
rev.2015-10
DATE
8530 West Sunset Roa d, Suite
230, Las Vegas, NV 89113
www.neva da gastro.com
conta ct@nevada gastro.com
office 702-483-4483 fax 702-410-6670
PATIENT MEDICAL HISTORY
Patient Name
How did you hear a bout us?Referring Physician
Internist/Prim ary Physician
Pharma cy
Pharma cy Add ress
Reason for visit:
DOB
Age
Phone#
Phone #
City
Zi p
Have you ever seen another gastroenterologist for this problem? □ No □Yes
If yes, who, where, when?
Have you bee n a dmitted to the hospital or presented to the ER re cently? □ No □ Yes
MEDICAL HISTORY—Che ck ALL p ast or present illnesses
GASTROINTESTINAL
MUSCULOSKETAL
□ IBS (Irrita ble Bowel Syndrome )
□ GERD/Heartburn
□ Barrett’s Esopha gus
□ Diarrhea
□ H. pylori infe ction
□ Peptic Ulcer Disease
□ Colonic polyp
□ Hemorrhoids
□ Diverticulosis/ Diverticulitis
□ Bow el obstruction
□ Gallstones
□ IBD- Crohn’s disease
□ IBD-Ulcerative Colitis
□ Pancreatitis
□ Chronic constipation
□ Gastrointestinal Blee ding
□ Stom ac h p olyp
□ Fibromyalgia
□ Rheumatoid Arthritis
□ Raynaud’ s
□ Lupus
□ Sjogrens
□ Scleroderma
□ Go ut
LIVER
□ Hemo c hrom a tosis
□ Cirrhosis
□ Hepa titis A
□ Hepa titis B
□ Hepa titis C
□ Liver cyst
□ Fatty Liver
PSYCHOLOGICAL
□ Bipolar
□ Anxiety
□ Depression
□ OCD
□ Schizophrenia
HEART
□ High Bloo d Pressure
□ Heart A ttac k
□ Angina
□ Co ngestive Heart Fa ilure
□ Palpitations
□ Mitra l Va lve Prolap se
□ Eleva ted C holesterol
□ Rheumatoid A rthritis
□ Heart valve disease
□ Endocarditis
CANCER
□ Co lon Canc er
□ Esophag eal Canc er
□ Stom ac h Cancer
□ Bre ast Canc er
□ Pa nc rea tic Cancer
□ End ome tria l Cancer
□ Prosta te Cancer
□ Liver Cancer
□ Leukem ia / Lymphom a
OTHER
BLOOD
□ Von Willebrands’
□ Hemo philia
□ Bleeding or clotting
Renal
□ Kidney Stones
□ Kidney Failure
□ Dialysis
NEUROLOGICAL
□ Stroke
□ Seizures
□ Migraines
□ Other Head a che
RESPIRATORY
□ COPD (Emphysema)
□ Asthma
□ Tuberculosis
□ Slee p Apnea
□ Colla psed Lung
ENDOCRINOLOGY
□ Diab etes
Typ e I (insulin nee d ed )
□ Diab etes Type II (oral
medications needed)
□ Hyperthyroid ism
□ Hypothyroidism
□ Hyperpa rathyroid ism
INTEGUMENTARY
□ Skin Cancer
□ Melanoma
□ Psoriasis
□ Vitiligo
□ Eczema
MEDICATIONS List ALL prescriptions, sup plements, and over the counter medications
Medication
Dose
Medication
1.
2.
3.
4.
5.
Dose
6.
7.
8.
9.
10.
ALLERGIES
□ No Known Drug Allergies □ Iodine □ Sulfa □ Aspirin □ Penicillin □Other:
ISSUES WITH ANESTHESIA: □ Yes □ No If yes please explain
SURGICAL HISTORY: Check ALL that apply
GASTROINTESTINAL
CARDIAC
GENITORURINARY
□ Ap pende ctom y
□ Liver Transplant
□ Hia tal Hernia Repair
□ Inguinal Hernia Rep air
□ Gallblad der Removal
□ Gastric Bypa ss
□ Gastric Banding
□ Sleeve Gastre ctomy
□ Colon Resection
□ Intestinal Rese ction
□ Ventral Hernia Repair
□ ERCP
□ Endoscopic Ultrasoun d
□ Heart Stent Pla cem ent
□ CABG (Coronary Artery)
□ Pa cem aker
□ Defibrillator
□ Heart Transplant
□ LVAD Device
□ Ab dominal Aneurysm Repair
□ Heart Valve Repla cement
□ TURP (Transurethral Rese ction of the
GYNECOLOGICAL
Prostate)
□ Cyste ctom y (Blad der Remo val)
□ Kidney Transplant
□ Nephre ctom y (Kidney
Remo val
□ Prostate ctomy (Prostate
remo val)
□ Radiation for prostate cancer
OTHER
FAMILY HISTORY Che ck ALL diseases that have o c curred in your family and indicate family member affe cted
□ Crohn’s Disease
□ Irrita ble Bowel Syndrome
□ Ulcerative Colitis
□ Celia c Disease
□ Liver Disease
□ Cirrhosis of Liver
□ Hemo chromatosis
□ Gallstones
□ Pancreatitis
OTHER:
□ Colon Polyps
□ Stoma ch Cancer
□ Esopha geal Cancer
□ Pancreatic Cancer
□ Colore ctal Cancer
□ Biliary Cancer
□ Uterine Cancer
□ Bre ast Cancer
□ Chronic Anemia
□Hystere ctomy
□ Ovary Remo val
□ C-se ction
□ Mastectomy
(R,L,B)
SOCIAL HISTORY
Smoking: Do you currently smoke? □ Yes □No
If yes, how many pa cks per d ay?
Smoked in the past? □ Yes □ No
If yes, when w as your quit d ate?
Alcohol: Do you drink alcohol? □ Yes □No
If yes, how many times in a week?
If yes, how many drinks ea ch time?
Drugs: Do you use illicit drugs? □ Yes □No
If yes, how often?
Type: □ Cocaine □ Ecstasy □ Heroin □ Marijuana □ Pain medications □ Other IV Drugs
GENERALIZED REVIEW OF SYMPTOMS Che ck ALL that a pply
CONSTITUTIONAL
NEUROLOGICAL
EYES, EARS,NOSE,THROAT
□ De creased ap petite
□ Excessive fatigue
□ Night Sweats
□ Weight Loss
□ Dizziness
□ Hea d a ches
□ Numbness/Tingling
□ Seizures
MUSCULOSKELETAL
□ Dentures/Partials
□ Ear pain/Ringing
□ Eye pain/Blurred vision
□ Hearing loss
□ Hoarseness
□ Ina bility to smell
□ Ne ck Lumps
□ Ba ck pain
□ Re cent injury
□ Swelling
SKIN
CARDIOVASCULAR
□ Irregular heartbeat
□ Leg swelling
□ Poor exercise tolerance
□ Chest Pain
ENDOCRINE
HEMATOLOGICAL
□ Excessive thirst
□ Cold intolerance
□ Menop ause
□ Weight gain(10+ lbs)
□ Weight loss
□ Anemia
□ Bleeding and / or bruising
□ Bloo d transfusion
□ Bruising
□ Itching
□ Jaundice
□ Rash
□ Skin cancer
□ Tattoo
PSYCHIATRIC
URINARY
RESPIRATORY
□ Suicid al Intention
□ Trouble Sleeping
□ Depression
□ Frequency of urination
□ Loss of bla dder control
□ Burning with urination
□ Chronic c ough
□ Slee p Apnea
□ Shortness of b rea th
□ Whee zing / Asthma
GI REVIEW OF SYMPTOMS Are you currently experiencing any of the following symptoms?
Abdominal Pain, if yes, for how long?
□ Intermittent (on and
off)
□ Constant
□ Burning
□ Sharp
□ Cramping
□ Relieved by p assing ga s
□ No relief with bowel movem ent
□ Dull Ache
□ Better with food
□ Worsened with food
□ No effe ct with foo d
□ Relieved by bowel
or passing ga s
□ Other
mo vement
Severity: 1 (mild) – 10 (severe)?
What improves the p ain?
What worsens the pain?
Bloating If yes, for how long?
□ Worse with foo d
□ Eructation (burping)
Heartburn, If yes, for how long?
□ Often
□ Not
Often
□ Flatulence (gas)
□ Aw aken you at night
□ Relieved with me dic ations:
Diarrhea, if yes, for how long?
□ Number of bowel mo vements per da y:
□ Blo od Present
□ Mucus Present
□ Recent Travel
□ Antibiotics in the past 3 mo nths
Rectal Bleeding, if yes, for how long?
□ Bright red blood □ Blood mixed in stool □ Blood on toilet pa per
Constipation, if yes, for how long?
□ Number of bowel mo vements per week?
□ Remo ve stool with finger som etimes
□ Require laxatives or enemas frequently
□ Sense of incomplete emptying
Food stuck in esophagus, if yes, for how long?
□ Liquids
□ Solids
□ Both
Painful swallow, if yes, for how long?
□ Liquids
□ Solids
□ Both
Vomiting, if yes, for how long?
□ Foo d
□ Bile (green)
Recent changes in bowel habits, □ Yes □ No If yes, for how long?
Please check all that apply for bowelhabits:
□ Alternating diarrhea and constip ation
□ Cramp-like p ain in the a bdomen
□ Pain before, during or after bow el
mo veme nt
□ Full quickly
□ Jaundice
□ Nervous bowel
□ Poor a pp etite
□ Thin stools
□ Bla ck stools
Any weight changes in the last 6 months? □ Yes □ No If yes, □ Loss or □ Gain How many pounds?
Have
Have
Have
Have
Have
you ever had upper endoscopy? □ Yes □ No If yes please explain da te and finding
you ever had colonoscopy? □ Yes □ No If yes please explain date and finding
you ever had abdominal CT scan? □ Yes □ No If yes please explain date and finding
you ever had abdominal ultrasound? □ Yes □ No If yes please explain d ate and finding
you ever had barium enema? □Yes □ No If yes please explain date and finding
_
OFFICE AND FINANCIAL POLICY
Thank you for choosing our pra ctice. We are c om mitted to providing the best possible me dic al
c are for you. In order to avoid any c onfusion, we ask that you rea d the following Office and
Financial Policy carefully.
Consent for Treatment:
I c onsent to trea tme nt, d iag nostic , a nd / or therap eutic servic es as ord ered a nd / or provid ed by the p hysic ia ns a nd a nc illa ry
provid ers of Kim Chen, PLLC, dba Com prehensive Digestive Institute of Nevada a nd d esignee (s).
Insurance Billing:
Your insura nc e p olic y is a c ontra c t b etwee n you a nd your insura nc e c ompa ny. It is your resp onsib ility to know your b enefits a nd
how they would ap p ly to your trea tment. We will b ill your insura nc e for servic es tha t we provid e; howeve r, a ny a cc ount b a la nc e
tha t is not pa id b y your insura nc e c om pa ny will b e the resp onsibility of you (or the g uara ntor listed on your insura nc e p olic y). If
our offic e d oe s not pa rtic ipa te with your insura nc e, it will b e your resp onsibility to file your insura nc e c la ims d irec tly with your
insura nc e. If you fa il to notify us of a n insura nc e c ha nge, you a re fully resp onsible for a ny a mount not pa id b y your insura nc e
c om pa ny.
Som e insura nc e p la ns req uire pre-c ertific a tion, p re-a uthoriza tion, or a written referra l. It is the p a tient's resp onsib ility to und ersta nd
their insura nc e p la n req uirem ents a nd ensure tha t the prop er a uthoriza tion is ob ta ined a t least 3 da ys prior to the da te of servic e.
Failure to d o so ma y result in d enial b y the insura nc e c om pa ny. We c a nnot a cc ep t resp onsibility for a d isp uted c la im.
For a ll servic es provid ed b y our p hysic ia n(s) in the hospital, we w ill b ill your health p la n. Any b a la nc e d ue is your resp onsib ility.
All d ed uc tib les a nd c o-pa yme nts w ill b e c ollec ted in full a t the time of servic e. Returned c hec ks are c harged a $25.00
ad ministra tive fee . Any acount unpaid over 90 days is considered past d ue and w ill b e c harged a $30.00 la te fee . If p a yme nt is
not rec eived, the a cc ount w ill b e turned over to our c ollec tion ag enc y and/ or attorney, this w ill b e subjec t to a 25% c harge to
c over the c olle c tor's fee . We w ill b e happ y to d isc uss your prop osed trea tme nt a nswe r q uestions rela ting to your insura nc e.
Our Billing Offic e c a n b e c onta c ted a t (347)732-1317.
Medicare:
We are p artic ipa ting provid ers of the Me d ic are prog ra m. We w ill a cc ep t assignme nt on a ll the c la ims. Pa tients are resp onsible
for mee ting their a nnual d ed uc tib le a nd p a ying c o-p a yme nt. We d o file with the sec onda ry / supp leme ntal c a rriers. Howe ver, if
the supp leme nta ry d oe s not pa y, pa tients w ill b e b illed the rem a ining ba la nc e the rem a ining b a la nc e. I req uest tha t pa yme nt
of a uthorized Me d ic are b enefits b e mad e either to me or on my b ehalf for a ny servic es furnished to me by Com prehensive
Digestive Institute of Nevada . I a uthorize a ny hold er of me d ic a l or other informa tion ab out me to release to the Ce nters for
Medic are & Medic a id Servic es or its a gents a ny informa tion nee d ed to d etermine these b enefits or b enefits for rela ted servic es.
No-Show/CancellationPolicy:
Please notify our offic e a t least 24 hours in a d va nc e if you are unab le to kee p your sc hed uled offic e app ointme nt. If you d o not
notify us a nd miss your a pp ointme nt, we w ill req uire tha t you p a y a $35.00 missed app ointme nt fee b efore we are a ble to
sc hed ule a nother offic e visit for you. For p a tients ha ving a proc ed ure, you w ill b e req uired to give our offic e a 48 b usiness hour
notic e if you are c anc eling your proc edure or you w ill b e c harged a $150.00 c a nc ella tion fee . All fees must be paid in full prior to
the scheduling of future appointments.
Phone Consultations:
After-hour phone c a lls are limited to urgent me d ic a l issues. All other me d ic a l matters (inc lud ing test results) must b e d isc ussed in the
offic e. It is the p a tient’ s resp onsib ility to c a ll for a ny results if not notified in a reasonab le a mount of time . If a test result, howe ver,
is c ritic a l, we ’ ll make every effort to notify you as soo n as p ossible.
Administrative Fee s:
All me d ic a l rec ord req uests are subjec t to a prepa ration fee of $15.
A fee of $45 w ill b e c ollec ted for c om p leting and returning ad ministrative forms (i.e. FMLA, d isab ility, etc ).
Acknowledgement and Authoriza tion:
I have read , understa nd and ag ree to ab ide b y the ab ove Offic e and Fina nc ia l Polic y.
MY SIGNATURE ACKNOWLEDGES RECEIPT OF THIS FORM / DATE
NOTICE OF PRIVACY
POLICIES AND
PRACTICES
FOR
Comprehensive Digestive Institute of Nevada
DEAR PATIENT:
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
INTRODUCTION
At Comprehensive Digestive Institute of Nevada, we are committed to treating and using protected health
inform ation a bout you responsibly. This Notice describes the personal inform ation we colle ct, and how and
when we use or disclose that inform ation. It also describes your rights as they relate to your prote cted health
inform ation. This Notic e a pp lies to all protected health inform ation as defined by federal regulations.
UNDERSTANDING YOUR MEDICAL RECORD / HEALTHINFORMATION
Ea ch time you visit Comprehensive Digestive Institute of Nevada a record of your visit is m a de. Typic ally, this
record contains inform ation ab out your visit including your examination, diagnosis, test results, treatment as well
as other pertinent healthc are d ata. This inform ation, often
referred to as your health or medic al record, serves as a:









Basis for planning your c are and treatment
Means of communic ation with other health professionals involved in your c are
Legal do cument outlining and describing the c are you received
A tool that you, or another p ayer (your insuranc e com p any) will use to verify that services billed were
a ctually provided
An educ ation tool for medic al health providers
A sourc e for medic alresearch
Basis for public health officials who might use this inform ation to assess and / or improve state as well as
national healthc are stand ards
A sourc e of d ata for planning and / or m arketing
A tool that we c an reference to ensure the highest quality of c are and p atient satisfa ction
Understanding what is in your record and how your health inform ation is used helps you to ensure it’s
a c cura cy, determine what entities have a c c ess to your health inform ation, and m ake an informed
decision when authorizing the disclosure of this information to other individuals.
YOUR RIGHTS
You have certain rights under the federal priva cy standa rds. These include:







The right to request restrictions on the use and disclosure of your prote cted health inform ation
The right to rec eive confidential communic ations concerning your medic al condition and treatment
The right to inspect and c opy your prote cted health inform ation. You m ay request an electronic copy if the
inform ation is m aintained electronic ally
The right to amend or submit corrections to your protected health inform ation
The right to re ceive an a c counting of how and to whom your protected health inform ation has been disclosed
The right to a restriction to disclosure of your protected health inform ation to a health plan for p ayment if you
have p aid in full for services provided in that visit.
The right to rec eive a printed copy of this notice
OUR RESPONSIBILITIES
Comprehensive Digestive Institute of Nevada is required to:
 Maintain the priva cy of your health inform ation
 Provide you with this Notic e as to our legal duties and priva cy pra ctic es with respect to inform ation we c ollect
and m aintain a bout you
 Abide by the terms of this notice
 Notify you if we are una ble to agree to a requested restriction
 Acc ommo d ate reasona ble requests you m ay have rega rding communic ation of health inform ation via
alternative means and / lo c ations
As permitted by la w, we reserve the right to amend or modify our priva cy policies and pra ctices. These changes in our
policies and pra ctic es m ay be required by changes in federal and state la ws and regulations. W hatever the reason
for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and pra ctic es
will be a p plied to all prote cted health inform ation th at we m aintain.
We will not use or disclose your health inform ation without your authorization, except as described in this notice. We
will also discontinue to use or disclose your health inform ation after we have re ceived a written revo c ation of th e
authorization a c cording pro cedures included in the authorization.
HOW WE MAY USE AND/ OR DISCLOSE YOUR HEALTH INFORMATION
We will use your health information for treatment. Your health inform ation m ay be used by staff mem bers or disclosed
to other health c are professionals for the purpose of evaluating your health, diagnosing medic al conditions, and
providing treatment. For exam ple: results of la boratory tests and pro cedures will be availa ble in your medic al record to
all health professionals who m ay provide treatment or who m ay be consulted by staff mem bers.
We will use your information for payment. Your health plan m ay request and rec eive inform ation on d ates of service,
the services provided, and the medic al condition being treated in order to p ay for the service rendered to you.
We will use your information for regular health operations. Your health inform ation m ay be used as nec essary to
supp ort the d ay-to-d ay a ctivities and m anagem ent of Com prehensive Digestive Institute of Neva d a. For exam ple:
inform ation on the services you received m ay be used to supp ort bud geting and financial reporting, and a ctivities to
evaluate and prom ote quality.
Business Associates. In some instances, we have contra cted sep arate entities to provide services for us. These
“ asso ciates” require your health inform ation in order to a c com plish the tasks that we ask them to provide. Som e
exam ples of these “ business asso ciates” might be a billing service, colle ction a gency, answering services and
com puter software/ hard ware provider.
Communication with family. Due to the na ture of our field , we will use our b est jud gment when d isc losing health
information to a fa mily memb er, other rela tives, or a ny other p erson tha t is involved in your c are or tha t you have
authorized to rec eive this information. Please inform the pra c tic e when you d o not wish a fa mily memb er or other
individual to have a uthoriza tion to rec eive yourinformation.
Research / Teaching / Training. We may use your information for the purp ose of researc h, tea c hing, and tra ining.
Healthcare Oversight. Fed eral la w requires us to release your information to an a p propriate health oversight a genc y,
public health authority or a ttorney, or other fed eral/ sta te a p p ointee if there are c irc umstanc es tha t require us to d o
so.
Public health reporting. Your health information may b e d isc losed to public hea lth a genc ies as required by la w.
Law enforcement. Your health informa tion may b e d isc losed to la w enforc ement a g enc ies, without your permission,
to sup p ort government audits and insp ec tions, to fa c ilita te la w-enforc ement investiga tions, and to c omply with
go vernment manda ted rep orting.
Appointment reminders. The pra c tic e may use your information to remind you a b out up c om ing a p p ointments.
Typic a lly, a p p ointm ent remind ers are sent by e-mail, text messa ge, or, a brief, non-sp ec ific messa ge may b e left on
your answering ma c hine.
Food and Drug Administration (FDA). We may d isc lose to the FDA health information rela tive to a dverse events with
resp ec t to foo d , sup p lements, produc t and produc t d efec ts, or p ast marketing surveillanc e information to ena b le
produc t rec a lls, rep a irs orrepla c em ent.
Worker’s Compensation. We may d isc lose health information to the extent authorized by and to the extent
nec essary to c omply with la ws rela ting to worker’ s c om p ensa tion or other similar prog ra ms esta b lished by la w.
Public Health. As req uired by la w, we may d isc lose your health information to p ublic health or legal authorities
c harged with preventing or c ontrolling d isease, injury or d isa b ility.
Notification. We may use or d isc lose informa tion to notify or assist in notifying a fa mily memb er, p ersonal representa tive, or
another p erson resp onsible for your c are, your loc a tion, and general c ondition. We may a lso use and share with third
p arties your e-mail a d dress as well as other c onta c t information as c om munic a tion too ls in a ttemp t to keep you informed
a b out up and c om ing information regarding prod uc ts and servic es whic h in our opinion may b e of interest and of
p otential b enefit to you. If you any reason you wo uld not like your c onta c t information shared and wo uld not like to rec eive
any suc h informa tion, you may simply op t out by c onta c ting us a t 702-612-9090.
Other uses and disclosures. Disc losure of your health informa tion or its use for any purp ose other than those listed
a b ove requires your sp ec ific written authoriza tion. If you c hang e your mind after authorizing a use or d isc losure of your
information you may sub mit a written revoc a tion of the authoriza tion. However, your d ec ision to revoke the
authoriza tion will not a ffec t or und o any use or d isc losure of informa tion tha t oc c urred b efore you notified us of your
d ec isio n.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have c om p la ints, questions or would like a d d itional information regarding this notic e or the p riva c y pra c tic es of
Com prehensive Digestive Institute of Neva d a p lease c onta c t Com prehensive Digestive Institute of Neva d a .
If you b elieve tha t your p riva c y rights have b een viola ted , p lease c onta c t the aforementioned pra c tic e Priva c y Offic er
or, you may file a c om p la int with the Offic e for Civil Rights, U.S. Dep artment of Health and Human Servic es. There will b e
no retalia tion for filing a c omplaint with either the pra c tic e’ s Priva c y Offic er or with the Offic e for Civil Rights.
MY SIGNATURE ACKNOWLEDGES RECEIPT OF THIS FORM / DATE
Tarek Amm a r, M.D., Gary Chen, M.D., Vijay Ja yara ma n, M.D., Andrew Kim, M.D.,
John Rya n, M.D., Christia n Stone, M.D., M.P.H.
Authorization for Release of Informa tion
I hereby authorize:
To disclose the following protected health information to:
Comprehensive Digestive Institute ofNevada
Fax (702) 410-6670
8530 West Sunset Roa d, Suite 230, Las Vegas, NV 89113; Phone (702)483-4483
Patient Name:
Date of Birth:
Social Security #:
Date of Rec ords:
All Rec ords
From:
To:
Si gnature of Patient orPersonal Representative
Date
Printed Name of Patient or Personal Representative
www.nevadagastro.com
Confidentiality Notice
PRIVILEGED AND CONFIDENTIAL: This document and the information contained herein are confidential and
protected from disclosure pursuant to Federal law. This message is intended only for the use of the
Addressee(s) and may contain information that is PRIVILEGED and CONFIDENTIAL. If you are not the intended
recipient, you are hereby notified that the use, dissemination, or copying of this information is strictly
prohibited. If you have received this communication in error, please erase all copies of the message and its
attachments and notify the sender immediately.
Staff Initials
10/2015
Tarek Amm a r, M.D., Gary Chen, M.D., Vija y Jayaraman, M.D., Andrew Kim, M.D.,
John Rya n, M.D., Christia n Stone, M.D., M.P.H.
Medical Office
8530 West Sunset Road , Suite
230, Las Vegas, NV 89113
Phone: (702) 483-4483
Fax: (702) 410-6670
Billing Office
Phone: (347) 732-1375
Durango Outpatient SurgeryCenter
8530 West Sunset Roa d, Suite
100 Las Vegas, NV 89113
Phone: (702) 789-5700
Fax: (702) 789-5656
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTHINFORMATION
Patient Na me:
Date of Birth:
Comprehensive Digestive Institute of Neva da is authorized by me to use or disclose my Prote cted Health Information (PIH) for
a purpose of treatment, payment, or healthc are operations. I have rea d this authorization and understand the designated
information will be disclosed only to the recipient(s) outlined below. I specific ally authorize any current employee or owner of
Comprehensive Digestive Institute of Neva da to disclose the information as outlined. I further understand that I retain the right
to revoke this authorization in writing at a later da te.
You may disclose the following health information (check all that applies):
Entire Medic al Rec ord
Certain Medic al Data / Information as related to:
( ) Date of servic e(s):
( ) Specific service(s) or proc edure(s):
( ) Specific c ondition(s):
( ) Specific medic ation(s):
( ) Other:
This authorization permits Comprehensive Digestive Institute of Neva da to send the protected health information to:
The patient has the right to revoke this authorization in writing. In order for the revoc ation of this authorization to be
effective, Comprehensive Digestive Institute of Neva da must rec eive the revoc ation in writing by Certified U.S. mail.
This authorization shall expire on
_ or NEVER. After this date, Comprehensive Digestive Institute of
Nevad a c an no longer use or disclose the patient’s protected health information without first obtaining a new
authorization form.
I fully understand and a cc ept the terms of this authorization.
Patient or Legal Guardian Signature
Date
10/2015