• Welcome to East Bay Center for Digestive Health

    EBCDH is the largest single specialty gastroenterology group practice in the East Bay and comprises seven Board certified gastroenterologists with first rate clinical training and a dedication to providing excellent diagnostic and clinical care. We also have a certified Nurse Practitioner and certified Physician Assistant who each have over 10+ years of experience in the field of Gastroenterology. We are committed to exceeding your health care expectations.

    You have been directed to this form because your primary care physician has referred you to our office and you are scheduled for an endoscopic procedure.

    Your colonoscopy and/or upper endoscopy will be performed at East Bay Endosurgery Center, a state of the art facility located in our building in Suite 135. Please see the instructions below for completing your
    REGISTRATION FORMS.

    Please complete and submit this registration form online at least 2 weeks prior to your procedure.

    **OF NOTE – these forms are separate and in addition to any information provided on the Patient Portal**

    It is very important that we review your medical history prior to your procedure to avoid any late cancellations due to unknown medical conditions.

    If you have not completed this online form prior to your procedure, you will be asked to complete paper forms at the time of your visit. Depending on your medical status, your procedure may need to be rescheduled or even cancelled.

    If you are driving, please allow time to find parking.

    If you have any additional questions, do not hesitate to call your Procedure Coordinator at the extension provided on your procedure instructions.

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  • CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

    I understand that as a part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. EBCDH, Inc. will use and disclose my protected health information (“Health Information”) as defined by federal and state law, in the manner described below:

    • A basis for planning my care and treatment.
    • A means of communication among the many healthcare professionals who contribute to my care.
    • A source of information for applying my diagnoses and surgical information to my bill.
    • A means by which a third party payer can verify that services billed were actually provided.
    • A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.

    I understand that I have the right:

    • To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested.
    • To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

    Any and all of the following Health Information may be disclosed by EBCDH, Inc. on my behalf below for the follow reasons:

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  • Check if you have any of the following:

  • Family History

  • Social History

  • Review Of Systems

    In the last 6 months have you experienced any of the following? Do you currently have?

    General

  • Eyes/Mouth/Throat

  • Cardiac

  • Respiratory

  • Gastrointestinal

  • Musculoskeletal

  • Skin

  • Neurological

  • Psychological

  • Blood/Lymph

  • PATIENT MEDICATION LIST

    So that we may maintain the highest quality in care and safety,
    please fill in ALL MEDICATIONS that you take.

    Please be sure to include all asthma, heart and blood pressure medications, any narcotics you may take (Percocet, etc.),
    and any over the counter or herbal medications, medical creams or sprays and any supplements

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  • East Bay Center for Digestive Health Medical Associates, Inc.
    Paul S. Chard, M.D., Ph.D., E. Michael Darby, M.D., Susie Ng Cohn, M.D.,
    Neil H. Stollman, M.D., Liana Vesga, M.D., Silvia M. Villagomez, M.D., Danny Wu, M.D.
    Direct Referral Screening Colonoscopy
    General Information and Colonoscopy Consent Form

    Background: In the United States, colorectal cancer (CRC) is the second leading of cancer deaths (lung cancer is the
    leading cancer). Approximately 150,000 new cases are diagnosed in the US every year. Screening has been shown to
    decrease death from CRC. Your primary care physician has referred you to have a screening colonoscopy.

    What is it? Colonoscopy is a procedure that allows your physician to see the inside of your colon and rectum using a
    flexible tube (about the width of your index finger) containing a light and camera. This technology gives the physician the ability to take biopsies and remove suspicious findings if any are seen.

    What to expect: On the day before the procedure you will not be allowed to eat ANY solid foods. However, you will be allowed to have clear liquids. Sometime during the DAY BEFORE the procedure you will begin a bowel preparation to “clean out” your colon. Please read the bowel preparation instructions for specific further details – these are sent to
    you once the procedure is scheduled.

    Because this test can be mildly uncomfortable, you will be receiving anesthesia to make you sleepy during the exam, but you will not lose consciousness and will be breathing on your own. Most patients do not recall having the procedures done because the sedatives can impair short-term memory. The procedure typically takes less than 30 minutes. Recovery time is typically less than 60 minutes. Due to the anesthesia you will be receiving, you will not be allowed to drive home from the procedure. You will need a responsible adult to take you home. You cannot take a taxi or other service, i.e. Uber.

    You can have a light meal after your procedure and the remainder of the day should be spent resting. Due to the anesthesia, your judgment might be impaired for the remainder of the day, so you shouldn’t make any big decisions or operate machinery. The next day you should be back to normal.

    RISKS, BENEFITS, AND ALTERNATIVES: The risk of serious consequence from screening colonoscopy is very low.
    Potential serious complications include, but are not limited to bowel perforation (approximately 1 in 1,000), a small risk of heavy bleeding after removal of polyps (approximately 1 in 1,000) and death (approximately 1 in 20,000). Other possible risks include adverse reaction to sedation, infection, missed lesions and cardiopulmonary compromise. Alternatives to a screening colonoscopy include a radiology test, a flexible sigmoidoscopy, yearly stool test cards, which check for blood, and choosing not to have investigation performed.

    If you have more specific questions regarding the procedure itself or the risks, benefits and alternatives, you are advised to make an office visit to fully answer all your questions before scheduling the procedure.

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  • NOTIFICATION

    In the event that you have a procedure scheduled with one of our physicians at East Bay Endosurgery Center:

    Please be informed that the physician who is rendering services to you has ownership interest in this facility.

    East Bay Endosurgery was designed and built specifically to provide outpatient GI endoscopy procedures and to meet the needs of our community. Our staff consists of licensed nurses and certified technicians who are specifically qualified to assist in endoscopic procedures. The combination of our physicians and this group of dedicated professionals ensures the highest quality health care for our patients. By signing this document you indicate that you are aware of their ownership interest and have been offered the opportunity to be treated elsewhere, but have decided to have your procedure performed at East Bay Endosurgery.

    Though the physician may be contracted with your specific health plan, in some cases the facility may not. The insurances listed below are contracted with the facility;

    Aetna, Alameda Alliance, CHCN (except Blue Cross), Blue Cross, Blue Shield, Cigna, First Health, Health Net, MEDI-CAL, Medicare, Pacific Care, United Health Care, PHCS, Great West, Interplan, Beech Street, Tricare, Three Rivers Provider Network, PHCS, GEHA, UMR, Humana, APWU and Multiplan.

    If your particular insurance is not listed, then it may not be contracted with the facility. Many insurance plans offer out-of-network benefits which allow you to use a nonparticipating facility, while others do not. In either case, East Bay Endosurgery will strive to keep your out-of-network expenses competitive with the rates charged by “in-network” hospital facilities. Please be aware that deductibles and co-insurances are due at the time services are rendered to you.

    As is customary, insurance plans make a distinction between the fee the physician charges and the fee the facility charges. Per standard billing practices, your insurance will be billed two separate claims for these services.

    When East Bay Endosurgery submits a claim to a non-contracted insurance, it is possible they will forward the payment directly to you because it is not “in-network”. We are asking for your cooperation in making this process run smoothly. When you receive the payment for the services provided, please sign and forward the payment to our office. Please remember that you are ultimately responsible for all charges. Should you have any questions regarding a bill for the doctor’s fee, please contact our billing office at (510) 763-3332. Should have you any questions regarding a bill for the facility fee, please call (510) 893-1600 #3.

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  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

  • I, have received a copy of the Notice of Privacy Practices for East Bay Center for Digestive Health.

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  • ACKNOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICY

  • I, have received a copy of the Financial Policy for Practices for East Bay Center for Digestive Health.

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