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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