HGI OPEN ACCESS QUESTIONNAIRE Logo
  • Houston Gastro Institute

  • 25230 Kingsland Blvd. Ste. 101 Katy, Texas 77494

    Call/Text: (281) 746-9284

    Fax: (832) 437-3206

    www.houstongastroinstitute.com

  • OPEN ACCESS QUESTIONNAIRE

  • INTRODUCTION

  • Houston Gastro Institute offers “OPEN ACCESS COLONOSCOPY” scheduling without an office visit for patients who are asymptomatic and are eligible for colon cancer screening.  If you prefer to schedule a pre-procedure office visit, you do not need to fill out these forms.  Please call / text our office at 281-746-9284 to schedule your office appointment.  Please verify with your insurance if you office visit is covered since you are asymptomatic.  Medicare and some insurances may not cover pre-screening office visits. 

    In order to proceed to schedule your open access colonoscopy, you can either fill out these forms or you can request your primary care physician (PCP) to send us the most recent office note with any bloodwork (within 1 year). Our fax is 832-437-3206 or email them to contact@drasamoah.com. 

    Our doctors will review the forms or medical records and determine if a pre-screening office visit is needed prior to your procedure.


    DOES MY INSURANCE COVER SCREENING / SURVEILLANCE COLONOSCOPY 100%?

    American Cancer Society recommends that people at average risk of colorectal cancer start regular screening at age 45.  However, some insurances cover screening starting at the age of 50.  Therefore, we strongly encourage you to contact your insurance to check your screening benefits prior to completing these forms. 

    Persons considered to be at average risk for colorectal cancer screening are asymptomatic and have no personal history of colorectal cancer or adenomatous polyps, no family history of colorectal neoplasia, no inflammatory bowel disease and no unexplained anemia.

    If you are recommended by your doctor to repeat the colonoscopy (surveillance) within 10 years for the reason(s) of personal history of colon polyps and/or family history of colon cancer/polyps, and/or IBD, we strongly encourage you to verify with your insurance prior to completing these forms as your insurance may not cover this as screening benefits even though you are asymptomatic.


    WHERE DO WE PERFORM PROCEDURES?

    Depending on your insurance network and the availability of the doctor’s, we will schedule you at one of the following Endoscopy Centers in Katy area.

    Zazen Surgery Center: 25230 Kingsland Blvd, Ste 103, Katy, TX 77494
    Houston Methodist West Hospital: 18500 Katy Freeway, Houston, TX 77094
    Memorial Hermann Katy Hospital: 23900 Katy Freeway, Katy, TX 77494

  • PATIENT DEMOGRAPHIC INFORMATION

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  • Please answer the following questions to your best knowledge,

  • * If you answer YES to any symptom on Question #1, you will NOT be eligible for screening colonoscopy as it is only for patients with no diagnostic symptoms. Please call/text our office at 281-746-9284 to schedule your office visit prior to scheduling you colonoscopy. Therefore, you do not need to continue to fill out the rest of the forms.

  • Please send us a copy of your last colonoscopy report and pathology report (if any) if it was done by another Gastroentorologist. Please fax to 832-437-3206 or email to contact@drasamoah.com.

  • Who in your family? When was it diagnosed?

  • If Yes, Please contact your Cardiologist / Pulmonologist / Nephrologist to send us the clearance to ouroffice at fax 832-437-3206 or email it to contact@drasamoah.com. The clearance must be received priorto scheduling your colonoscopy.

  • Thank you for completing these forms. please send all the following document to contact@drasamoah.com or fax to 832-437-3206.

    1. Open Access Colonoscopy questionnaire or last PCP visit note with any recent labwork (within 1 year)

    2. Copy of the picture ID

    3. Insurance card(s) front and back

    Our Procedure Coordinator will contact you within 5 days to schedule your colonoscopy appointment uponour doctor’s review.

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