Download New Patient Packet - Florida Digestive Specialists

Florida Digestive Specialists
Gastroenterology and Liver Disease Management
Over 30 Years of Service
5767 49th Street North, Suite A
1417 S. Belcher Road, Suite A
St. Petersburg, FL 33709
Clearwater, FL 33764
Phone: (727) 443-4299 Fax: (727) 443-0255
Welcome to Florida Digestive Specialists, P.A. Please read and sign our office policy regarding insurance and billing.
We are preferred providers for many insurance companies. Please check with our office or consult your insurance
handbook if you have questions. We will be happy to file with your insurance on your behalf. You will be responsible
for all deductibles, copays, coinsurances at the time of service, in addition to any non-covered services.
We accept Medicare assignment and many HMOs. If you are a member of an HMO, you must obtain prior
authorization for all services through your primary care physician.
Patients without insurance coverage are expected to pay in full at the time of service, unless prior arrangements have
been made with our office.
All charges not paid by your insurance company are your responsibility.
Please advise our office whenever you have a change of address, phone number or insurance coverage.

If an appointment is not cancelled at least 48 hours in advance you will be charged a
twenty five dollar ($25.00) fee; this will not be covered by your insurance company.

If your procedure is not canceled at least 72 hours in advance you will be charged a
seventy five dollar ($75.00) fee; this will not be covered by your insurance company.
If you miss 4 appointments without cancelling or no show, it will require us to consider
discharging you from the practice
Thank you for your cooperation!
I have read and fully understand the above financial policy.
Patients Name:
DOB:
Patients Signature:
Date:
1
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Florida Digestive Specialists
Gastroenterology and Liver Disease Management
Over 30 Years of Service
5767 49th Street North, Suite A
1417 S. Belcher Road, Suite A
St. Petersburg, FL 33709
Clearwater, FL 33764
Phone: (727) 443-4299 Fax: (727) 443-0255
PRESCRIPTION REFILL POLICY
Currently our office receives a large volume of calls daily for medication refill requests. Effective July 1st,
2015, we have a new prescription refill policy. We understand that this is a change for both you and us
therefore we hope to work together during this transition to ensure safe and high quality medical care.
1. Please bring all your prescription bottles/medication that you are currently taking to your
appointment. This is important to make sure that you are taking the correct medications and the
correct doses. We will continue to take the time to carefully review your medication and write any
necessary refills at your office visit. We will also ask you to review the new prescription to make sure
that they are written correctly.
2. We do require office visits on a regular basis for all of our patients taking prescription medications.
The interval will vary depending on the type of medication prescribed. Please be sure you have
enough medication to last until your next scheduled visit. If you have not been seen at our office
within one year your Provider will need to review your chart before they can refill your medication.
As long as you have been seen within 3 years we can give you a prescription pending the Provider’s
approval. The Provider will need to call and speak with you regarding the prescription for enough
medication and how much of a supply is needed. You will also need to make an appointment with
your provider within 2 weeks of the medication being prescribed.
3. All prescription refill request should originate from the patient by contacting your local pharmacy
to see if there are available refills. If no refills are available the Pharmacist will contact our office for
a refill. All refill requests should be approved or disapproved by our office within 2 business days.
4. If you need a refill but are overdue for a follow-up visit and or blood work (necessary for
monitoring the safety or effectiveness of a medication), the provider may agree to call in enough
medication to a local pharmacy to last until we are able to schedule an office visit. It is your
responsibility to schedule an appointment before you run out of medication. You should schedule
your next visit before you leave our office.
5. Please remember to advise our clinical staff if you are changing your local pharmacy; you are going
on an extended vacation and need extra medication; if you will be using an out of town pharmacy
while on vacation; and or changing to a new mail order pharmacy. This will allow us to ensure
prescriptions are filled in a timely manner.
6. Prescription refills will only be handled during office hours Mon – Fri, 8am to 5pm. No prescriptions
will be filled during evenings and weekends.
2
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Florida Digestive Specialists
Gastroenterology and Liver Disease Management
Over 30 Years of Service
5767 49th Street North, Suite A
1417 S. Belcher Road, Suite A
St. Petersburg, FL 33709
Clearwater, FL 33764
Phone: (727) 443-4299 Fax: (727) 443-0255
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I HEREBY AUTHORIZE
to release information from my medical records, including information of a psychological, psychiatric and alcohol
or drug-related nature, HIV/AIDS:
To:
From:
Date of Hospitalization:
Patient’s Printed Name:
DOB:
Patient’s Signature: ___________________________________________
Information Requested
( ) Discharge Summary
( ) Operation Report(s)
( ) X-ray Report(s) & Film(s)
( ) Psychological Records
( ) Alcohol/Drug Related
( ) Office Visit(s)
( ) Other
DATED: This
( ) History & Physical
( ) Pathology Report(s)
( ) Laboratory Report(s)
( ) Psychiatric Record (s)
( ) AIDS/HIV Records
( ) All of the above
Day of
, 2016
Witness:
Patient:
Witness:
Relative
or Legal Guardian
*Authorization must be signed by the patient, or by the parents if patient is a minor; or by nearest relative or CourtAppointed Guardian if patient is physically or mentally incompetent.
3
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Florida Digestive Specialists
Gastroenterology and Liver Disease Management
Over 30 Years of Service
5767 49th Street North, Suite A
1417 S. Belcher Road, Suite A
St. Petersburg, FL 33709
Clearwater, FL 33764
Phone: (727) 443-4299 Fax: (727) 443-0255
CONFIDENTIALITY QUESTIONNAIRE
PLEASE PRINT the family members or other persons, if any, whom we may inform about your general
medical condition and your diagnosis (including treatment, payment and health care options).
Name:
Home # (
Relationship:
)
Cell # (
)
Work # (
Name:
Home # (
)
Relationship:
)
Cell # (
)
Work # (
)
Please list the family member or significant other, if any, whom we may inform about your medical
condition ONLY IN AN EMERGENCY.
Name:
Home # (
Relationship:
)
Cell # (
)
Work # (
Name:
Home # (
)
Relationship:
)
Cell # (
)
Work # (
)
May we leave a message on your answering machine/voice mail regarding your results or health care
information?
Yes
No
Please note that in an emergency or for the purpose of your care and when the medical information is
directly relevant to that person’s involvement with your care, we may disclose your medical information
to family members, other relatives or close personal friends other than the above listed.
PATIENT NAME (please print):
DOB:
Patient/Representative Signature:
Date:
4
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Florida Digestive Specialists
Gastroenterology and Liver Disease Management
Over 30 Years of Service
5767 49th Street North, Suite A
1417 S. Belcher Road, Suite A
St. Petersburg, FL 33709
Clearwater, FL 33764
Phone: (727) 443-4299 Fax: (727) 443-0255
Patient Name: _________________________________________ DOB: _____________ Date: _____________
Please circle Yes or No in answer to the following medical history questions.
Do you have any allergies to medications, eggs and or Latex? YES / NO
Please list any allergies: ______________________________________________________________________
What medications are you currently taking? _____________________________________________________
Please list any previous surgery:
Type of surgery
Year
_______________________________
____________________
_______________________________
____________________
_______________________________
____________________
_______________________________
____________________
Please list any active medical problems: _________________________________________________________
If you have had seizures, please provide the date of your most recent seizure:__________________________
YES / NO Are you on Coumadin/(Warfarin Sodium), iron supplements (incl. vitamins), Lovenox, Plavix, Xarelto?
YES / NO On Oxygen or CPAP?
YES / NO Currently infected with HIV or TB?
YES / NO Had a coronary/vascular stent within the last year?
YES / NO Had a heart attack or stroke in the last 6 months?
YES / NO Had intestinal surgery within the last 3 months?
YES / NO Problems with: sedation/anesthesia, opening your mouth, breathing tubes?
YES / NO Are you on therapy for heartburn and/or other GERD symptoms?
YES / NO Do you have chronic heartburn? (2 times or more per week)
YES / NO Have you had an upper endoscopy in the past 30 days? If so, where _______________ when ___________
YES / NO Do you see blood in your bowel movements?
YES / NO Been hospitalized in the last month? If so, where _________________ when ________________
YES / NO Been diagnosed with a known bleeding disorder or Anemia?
YES / NO Had heart pain (angina) or breathing problems in the last 3 months?
YES / NO Had kidney failure?
YES / NO Do you have frequent constipation or diarrhea?
YES / NO Unexplained weight loss greater than 10lbs in the last month?
YES / NO On chronic narcotic pain medicines? If so, how often? _______________
YES / NO Had heart valve surgery?
YES / NO Do you have abdominal pain? Describe ___________________________________________
YES / NO Do you have a defibrillator/pacemaker or combination of both?
YES / NO Personal history of Congestive Heart Failure (CHF), renal failure/insufficiency?
YES / NO Had joint replacement in the last 6 months?
YES / NO Had a colonoscopy previously? When? _______________ Where? ___________________
YES / NO Do you weigh more than 350 pounds?
YES / NO Do you have relatives with colon cancer/colon polyps? If so, who? ________________ What? __________
YES / NO Been diagnosed with diabetes and on insulin or oral diabetic medication?
YES / NO Are you confines to a wheelchair?
5
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Rectal Bleeding
Vomiting
General/Constitutional:
Appetite Reduced
Fatigue
Fever
Night Sweats
Weight Gain
Weight Loss
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
O No
O Yes O No
O Yes O No
Hematology:
Blood Transfusion
Abnormal Bleeding
Anemia
Easy Bruising
Allergy/Immunology:
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
O No
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
O No
O No
O No
O No
Genitourinary:
Seasonal Allergies
O Yes O No
Passing Stool/Gas from Vagina
Blood in Urine
Urinating at night
Pain with Urination
Urinary Incontinence
Vaginal Bleeding
HEENT/Neck:
Change in Vision
Loss of Hearing
Hoarseness
Mouth Sores
Sore Throat
Swollen Lymph Nodes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
O No
Musculoskeletal:
Osteoporosis
Swelling legs or feet or pale extremities
Arthritis
Bone Pain
Muscle Aches
Endocrine:
Cold Intolerance
Diabetes
Heat Intolerance
O Yes O No
O Yes O No
O Yes O No
Dermatologic:
Itching
Jaundice (yellowing of skin and/or eyes)
Psoriasis
Rash
Skin Cancer
Respiratory:
Asthma
COPD/OSA (use of C-PAP machine)
Cough
O Yes O No
O Yes O No
O Yes O No
Coughing up blood
Shortness of Breath
Wheezing
O Yes O No
O Yes O No
O Yes O No
Neurologic:
Loss of Strength/Sensation
Balance Difficulty
Confusion
Dizziness
Headache
Seizures
Speech Abnormality
Strokes
Tingling/Numbness
Cardiovascular:
Chest Pain
Shortness of breath
Shortness of breath (lying down)
Palpitations
PND (shortness of breath during sleep)
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
Gastrointestinal:
Psychiatric:
Abdominal Pain
Black Stools
Bloating
Change in Bowel Habits
Constipation
Diarrhea
Problem and/or pain with swallowing
Feels full fast after eating
Heartburn
Vomiting blood
Hemorrhoids
Unintentional passing of Stool
Nausea
Pain when Swallowing
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O No
O No
O No
O No
O No
O No
O No
O No
O No
O No
O No
O No
O No
O No
Anxiety
Depression
Eating Disorder
O Yes O No
O Yes O No
O Yes O No
Name:
Date:
DOB:
6
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Medication Lists
Name of Medication
How often are you taking the
medication
Dosage
7
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Social History
Date:
Patient Name:
DOB:
These questions are only intended to assist in your healthcare. Please circle or check:
Do you smoke cigarettes?
No
Yes
Do you drink alcohol currently?
No
Yes
If yes, how much do you drink? (1 serving=12oz beer, 5oz wine or 1.5oz liquor)
please check:
____ Occasional use-less than 3 servings per month
____ Less than 7 servings per week
____ More than 2 servings per day
____ More than 7 servings per week
If these do not apply, please indicate other amount:
______ Servings per ________________
The following questions refer to recreational drug use:
Have you ever snorted drugs (intranasal)?
No
Yes
Have you ever used intravenous (IV) drugs?
No
Yes
Have you used any drugs other than what’s prescribed to you in the past 6 months?
No Yes
If yes, what did you use? ________________________________
8
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner
Florida Digestive Specialists
Gastroenterology and Liver Disease Management
Over 30 Years of Service
5767 49th Street North, Suite A
1417 S. Belcher Road, Suite A
St. Petersburg, FL 33709
Clearwater, FL 33764
Phone: (727) 443-4299 Fax: (727) 443-0255
FDS PHONE MENU
We have a high call volume therefore we want your experience calling the office to be a
pleasant one. Therefore we have created a patient friendly phone menu to better server
you. At times you may encounter our answering service due to overflow but rest assured
our staff will return your call promptly.
Phone Number – 727-443-4299
Press Option 2 for: Locations, addresses and fax number.
Press Option 3 for: New Patient Appointments (Ext. 1208)
Press Option 4 for: All other appointments and or if you are a Doctor’s Office
calling.
Press Option 5 for: Prescription Refills; prior authorization for prescriptions;
questions related to your upcoming procedure.
Press Option 6 for: Billing questions, authorizations and or referrals for not
related prescription.
Press Option 7 for: Medical Records (Ext. 1251)
Patient Triage Line: 727-443-4299 ext. 1227
9
Jay K. Kamath, M.D.
Gastroenterologist
Sally Follett, ARNP-C
Nurse Practitioner
Lina Hernandez, ARNP-C
Nurse Practitioner
Amie Eller, ARNP-C
Nurse Practitioner