Alabama Bariatrics New Patient Form

Patient Information
Patient's Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Physician
Physician's Phone #
Please enter a valid phone number.Format: (000) 000-0000.

Pharmacy Information
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City
State

Emergency Contact
Name
Relationship
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Insurance Information
Primary Insurance Information
Primary Insurance Plan Name
Copayment $
ID #
Group #
Name of Insured
Relationship to patient
Insured's SSN
Insured's D.O.B.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Insurance Information
Secondary Insurance Plan Name
Copayment $
ID #
Group #
Name of Insured
Relationship to patient
Insured's SSN
Insured's D.O.B.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby assign, transfer, and set over to Alabama Bariatrics and Minimally Invasive Surgery, P.C. all rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. If this account is submitted to collections, I, the undersigned, agree to any and all collection costs and reasonable attorney fees. Returned checks will incur a $35 fee. Please call 24 hours in advance to cancel your appointment.
Patient's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Alabama Bariatrics

Surgery & Procedure Cancellation/No-show Fee Consent
Bariatric surgery:

Surgery must be cancelled at least 5 days before the date of scheduled surgery. Surgery must also be performed within 1 year of the approval date. If you cancel or no show in under 5 days of the scheduled surgery date, or if you have expired your approval, you will be responsible for a $500.00 surgery cancellation/no-show fee.

Fluoroscopic band adjustments:

Scheduled fluoroscopic band adjustments must be cancelled/rescheduled at least 3 days/72 hours prior to your scheduled date. If you fail to cancel or reschedule before that time, you will be responsible for a $125.00 cancellation/no-show fee.

EGD:

Scheduled EGD's must be cancelled/rescheduled at least 3 days/72 hours prior to your scheduled date. If you fail to cancel or reschedule before that time, you will be responsible for a $125.00 cancellation/no show fee.

Why do we do this? When patients cancel and no-show at the last minute, this delays others that have been waiting patiently from getting scheduled in a timely manner. We do this to help YOU be able to get your procedure and surgery as soon as we possibly can!
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Alabama Bariatrics and Minimally Invasive Surgery, P.C.

Decatur | Huntsvile

P: 256.274.4523 F: 256.203.8791

W. Jay Suggs, M.D. FACS, FASMBS / Andrew Harner, M.D.

NON-COVERED SERVICES WAIVER
Patient Name
Date of Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance
I understand that my insurance company may or may not cover services provided to me today. This may include an office visit. I also understand that none of my diagnoses will be changed to satisfy insurance requirements. I understand that I am fully responsible for any charges that my insurance company does not cover for whatever reason. Should I proceed forward with surgery, I understand it is my responsibility to pay the $125 program fee that is not covered by insurance. Any charges denied by my insurance company prior to my surgery or procedure must be paid in full. If not, I understand that my surgery or procedure will be postponed until my financial obligations are met.

Physician Ownership Disclosure:

Federal regulation also requires physicians to advise patients if they have ownership interest in facilities. Currently, Dr. Suggs owns shares of Decatur Ambulatory Surgery Center.
Email/Text message agreement:
Signature of Patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Witness
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Alabama Bariatrics

NON-COVERED SERVICES WAIVER
Policy Holder
Patient/Agent or Representative, Relationship
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name

First NameLast Name

HIPAA Consent for Purpose of Treatment, Payment and Healthcare Operations, Notice of Privacy Policy Acknowledgement
Signature of Patient or Personal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name or Patient or Personal Representative
Relationship to patient

Rows	YES	NO	NOTES
Borderline diabetes (no medications)
Diabetes - Insulin
Diabetes - Medications
Sleep Apnea (note if on CPAP)
Asthma
COPD
Use of home oxygen
Cancer (what type?)
Hypertension (high blood pressure)
Heart: History of heart attack
Heart: History of angina or chest pain
Heart: Coronary artery disease
Heart: Heart failure
Heart: Pacemaker
Stroke or TIA
High cholesterol/triglycerides
Hyper or hypothyroidism (note which)
Acid reflux (GERD)
History Stomach Ulcers
Gallbladder: gallstones
Gallbladder: gallbladder attacks
Anemia
HIV/ AIDS
Anxiety disorder
Bipolar disorder
Depression
Suicide attempt
Arthritis: Knee pain
Arthritis: Hip pain
Lower Back Pain
Leg / foot swelling
Venous stasis disease: Leg ulcers
Venous stasis disease: Lymphedema
Pulmonary embolism (note IVC Filter if you have one)
Blood Clots (DVT)
Stress urinary incontinence
Kidney disease (note if on dialysis)
Liver Disease (circle): NASH Fatty Liver
Cirrhosis
Menstrual history: Post-menopausal
Menstrual history: Infertility or PCOS (note which)
Last mammogram (year):
Last Colonoscopy (year):
Last EGD (upper endoscopy) (if ever)
Other Medical Problems or Hospitalizations (List)

Rows	YES	NO	NOTES
Any abdominal surgery?
Hernia repair (abdominal, groin, etc.)?
Gallbladder removal (cholecystectomy)?
Previous Bariatric Surgery?
Hysterectomy?
Colon resection?
Nissen fundoplication/hiatal hernia repair?
Joint replacement?
Open heart surgery?
Others (describe)

Rows	NOTES
Packs Per Day
Years Smoked
Quit Date
Vaping: Y/N Quit Date:

Rows	YES	NO	NOTES
Smoke Marijuana
Medical Marijuana or cannabis
Marijuana or cannabis edibles
How Often:

Rows	NOTES
Servings per week
History of treatment for alcoholism/drug abuse:

Patient Information

Pharmacy Information

Emergency Contact

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Alabama Bariatrics

Surgery & Procedure Cancellation/No-show Fee Consent

Bariatric surgery:

Fluoroscopic band adjustments:

EGD:

Alabama Bariatrics and Minimally Invasive Surgery, P.C.

Alabama Bariatrics

Authorization for Release of Medical Documentation

Alabama Bariatrics

NON-COVERED SERVICES WAIVER

HIPAA Consent for Purpose of Treatment, Payment and Healthcare Operations, Notice of Privacy Policy Acknowledgement

MEDICAL HISTORY

Patient Health Questionnaire/Review of Systems

Alabama Bariatrics GERD Questionnarie

Rows	YES	Family Member(s)
Obesity
Bleeding disorder
Heart disease
Diabetes
High blood pressure
Stroke
Cancer
l am adopted and do not know my family history.

Rows	YES	NO
I get a burning feeling in the middle of my chest.
I get pain in the upper part of the middle of my abdomen.
I often have this feeling after a meal or at night.
This burning feeling gets worse when I lie down or bend over.
Over the counter medicines such as acid reducers or antacids help.
I frequently regurgitate (burp up) my food.
I have difficulty or pain with swallowing.
There is a bitter or sour taste in the back of my throat.
I get nauseated.
I have a frequent cough.
I frequently have to clear my throat.
I am often hoarse.
My throat is sore or burns a lot.
Thave excess throat mucous or postnasal drip.
Thave changed my diet because of heartburn.
Thave bloating or gassy feelings.
Thave asthma or difficulty breathing.
Thave dental erosions or gum disease.
I have anemia.
Thave a vitamin 812 deficiency.
I vomit blood.
I have blood in my stool, or it's dark and tarry.

Rows	NAME	DATE
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