Welcome to Our Practice!

Please fill out the information found below to the best of your ability.

Patient Medical History 

Have you ever had the following? (NO or YES)

Any Family Medical History of: (if yes, please list family member(s))

Review of Systems: Please indicate any personal history below.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.

(Please make sure your Name, DOB & Today's Date are listed above

Please list all prescribed medications, including vitamins, over-the-counter, and as needed.

EMERGENCY CONTACT: (phone # must be different than patient's phone #) 

Secondary Insurance Company: 

Privacy Consent - For the Use & Disclosure of Protected Health Information (PHI)

This consent is required by the Health Insurance Portability & Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information. I hereby give my consent to DDC and the Endoscopy Center of Northern Ohio to use and disclose my protected health information for the purposes of treatment, payment and operations of my health care and this practice. Consent for treatment: I, with my signature, authorize (this practice), and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include (but limited to) preventive, diagnostic therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professional for care and treatment. Consent for release of information for payment and operations: I also authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I further consent to the use for any practice operational needs as identified in the practice privacy notice. Consent related to the Privacy Notice: I have had a chance to review the Practice Privacy Notice as part of this registration process.I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement. I understand that this practice may refuse me services if I refuse to sign this consent. I may revoke this consent at any time, but the practice may refuse further services at that time. If I revoke this consent, the revocation does not take affect until the practice receives it.

I hereby revoke the consent given above:

Consent for assignment of benefits: I consent to assign all payments for these services to this practice. I understand that I am responsible for all co-payments, amounts applied to deductibles and other amounts that may be deemed my responsibility by the payment sources, as required by my contract with my insurance plan and state regulation. I further understand that my contract with my insurance entity may or may not cover some services. It is my responsibility to obtain information from my health plan about service coverage. If I seek care outside of the contract, I am aware that I may be responsible for all charges that are incurred.

We now require all deductibles and co-pays be paid prior to or at the time of service. Any outstanding balances are to be paid in full within a 90-day grace period. All accounts over 90 days old are subject to a monthly interest charge of 1.5%, annual rate of 18%. Please make every effort possible to satisfy balances accordingly to avoid accumulating interest and possibly having your account turned over to a collection agency. Patients who have their accounts turned over to a collection agency are discharged from our Practice and are subject to an additional $25.00 collection fee. If you have any questions regarding this policy speak to a member of our Billing Department.

At Digestive Disease Consultants and the Endoscopy Center of Northern Ohio, our goal is to serve our patients with quality care in a timely manner. To provide the best care in a timely manner, we must implement a cancellation / no-show policy to ensure availability in the office, as well as in our ambulatory surgical center for our patients who are in urgent need of care. We ask every patient to be considerate to others and to please cancel an appointment in advance SO that another patient can be cared for in a timely manner as there is a high demand for available appointments. We understand that there are circumstances and emergencies prohibiting early cancellation and thus these circumstances will be considered, and a one-time exception can be granted based on the situation. Otherwise, if you do not cancel within 24- hours of your appointment, you will be subject to a cancellation / no-show fee of $100.00. This fee is not covered by insurance and as a patient of this practice, it will your full financial responsibility. How to Cancel Your Appointment To cancel your appointment, please call the Digestive Disease Consultants office at 330-225-6468, Monday-Friday 8:00 AM through 4:30 PM. You can also call our answering service 24-hours a day at 888-445-9932. If you are having problems reaching our staff, please leave a message with your name, date of birth, and your reason for calling.

Ihave read these policies in full; I understand and agree to the terms of these policies.