HGI Demos and Consent Form 2025

25230 Kingsland Blvd., STE 101 Katy, TX 77494

Call/Text: (281) 746-9284

Fax: (832) 437-3206

www.houstongastroinstitute.com

Name*

First NameLast Name

DOB*

Gender

Marital Status

Address

Primary Phone #(cell / work / home)

Secondary Phone#(cell / work / home)

Patient Email Address

example@example.com

How did you hear about us

Race

Language

Ethnicity

Pharmacy (Name & Address)*

Pharmacy (Phone)*

Primary Care Doctor Full Name & Phone # or None*

Type "None" or "N/A"

Referring Doctor Full Name & Phone # or None*

Type "None" or "N/A"

Emergency Contact Name

Phone Number

Relationship to Patient

Do you authorize this emergency contact to receive your health information? Yes / No

Primary Insurance Name*

Member ID/Policy Number*

Primary Policy Holder Name

DOB

Relationship to Patient

Secondary Insurance Name

Member ID/Policy Number

Primary Policy Holder Name

DOB

Relationship to Patient

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. The information obtained by the office of Houston Gastro Institute can and will be used to:

Conduct, plan and direct treatment
Obtain payment from third party payers
Conduct normal healthcare operations such as quality assurance

I have had the opportunity to read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I also understand that the office of Houston Gastro Institute has the right to amend this notice and that I am entitled to an updated copy of this notice if requested.

I understand that I may request in writing to restrict how my health information is used or disclosed by the office of Houston Gastro Institute to carry out treatment and healthcare operations. However, I understand that the facility may not accept these requested restrictions, but if accepted must abide by treatment.

I understand that I have the right to review and copy my health information and request a change to any information that I believe is not a complete list of each disclosure of my protected health information.

Power of Attorney:

I have a designated Legal/Medical Power of Attorney (POA) who is responsible for making all medical decisions on my behalf:I have not designated a Legal/Medical Power Of Attorney (POA) .

Name of POA:

Phone Number

Relationship to Patient

Email Address

example@example.com

I understand that a copy of the legal Power Of Attorney form must be provided to the office of Houston Gastro Institute before services can be rendered.

Authorize Person to Receive Health Information:

Patient OnlyOther: Please provide details

Name

Phone Number

Relationship

I understand that I may revoke or terminate this authorization at any time by submitting a written request to the office of Houston Gastro Institute.

Signature of Patient or Representative

Date

Print Patient Name

If Representative Name and Relationship to patient

Patients Name

Date of Birth

Date

I request and authorize the following practice:

Name of Hospital/Provider:

Phone Number

Fax Number

To release or obtain the patient's medical records requested below to:

Dr. Vivian Asamoah & Dr. Ting-Hui Hsieh

25230 Kingsland Blvd, Ste 101, Katy, TX 77494

Tel: 281-746-9284 Fax: 832-437-3206

contact@drasamoah.com

I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/ or treatment for HIV (AIDS VIRUS), sexually transmitted diseases, psychiatric disorders/ mental health, or drugs and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing or treatment.

This request and authorization applies to the release of records indicated below.

Please fax records to (832) 437-3206

Consult Notes

Operative Notes

ER Records

Colonoscopy Report

EGD

Report

Pathology Results

Labs

CT Results

Ultrasound Results

MRI Results

Pill Cam

All Records Continuation of Care

Other: ____________________________________________

Note to Office: ______________________________________

Signature of Patient or Representative

Print Patient Name

Date

If Representative Name and Relationship to patient

For Office Use ONLY:

Request To Obtain RecordsRelease Records

This form outlines key agreements regarding your care at Houston Gastro Institute. Please read carefully before signing. By signing below, you acknowledge that you have read, understood, and agree to the policies described and consent to evaluation and treatment by our medical professionals.

General Practice Policies

Informed Consent: Before any surgical procedure or significant treatment, medical professionals will provide a detailed explanation of its nature, purpose, benefits, and potential risks. You will have the opportunity to ask questions, and informed consent will be obtained before proceeding.

Anti-Racism and Anti-Hate Statement: The institute is committed to fostering inclusivity, respect, and equality, firmly standing against racism, discrimination, and hate. They strive to create a safe space for all individuals regardless of race, ethnicity, nationality, religion, gender identity, sexual orientation, and socioeconomic status.

Acknowledgment of Financial Policy

It is your responsibility to provide current insurance and billing information and to understand your insurance coverage. If a claim is denied, you will be financially responsible. You are expected to pay your co-payments, deductibles, or any outstanding balances at the time of your visit. If paying out-of-pocket, full payment is expected at the time of service.

Third-Party Billing: For diagnostic services (e.g. labs, imaging, specialty testing) ordered from third parties, it is your responsibility to verify network coverage and benefits with your insurance. The office does not handle these verifications or submit claims for these services.

Cancellation and No-Show Fees: A $50 will be charged for an office appointment and $150 for procedure appointment for "No Show" and cancelling or rescheduling without 48-hour notice. All fees must be collected before you can reschedule an appointment.

Medical Record Fee: Requests for hard copies of medical records are subject to a $25 administrative fee.

Administrative forms Fee: e.g. FMLA, Disability Forms that need to be completed by the physician are subject to a $50 administrative fee.

Acknowledgment of Privacy Practices (HIPAA)

You have certain rights to privacy regarding your protected health information under HIPAA. Your health information will be used for your treatment, to obtain payment from third parties, and for normal healthcare operations (like quality assurance You have the right to review and copy your health information and request changes if you believe it's incomplete. You can also request in writing to restrict how your information is used or disclosed, though the facility may not always accept these restrictions.

Group Nutrition Visit Consent

These are virtual group visits led by Dr. Vivian Asamoah and a Registered Dietician offering education and personalized recommendations on nutrition and lifestyle to help manage or potentially reverse conditions like GERD (Acid Reflux), Fatty Liver, and Constipation, and Gluten Sensitivity. Other patients will be present. While everyone is asked to keep information confidential, complete privacy cannot be guaranteed in a group setting. Your insurance may cover this program, or you can choose a self-pay option of $50 per session if not covered.

Patient Consent & Acknowledgment Form (continue)

AI Scribe Usage

An AI scribe will transcribe and document your medical visit conversations. It helps your physician focus on you, improving communication and care quality. It also creates more accurate and comprehensive documentation of your health history. This may help reduce wait times and make your visits more efficient. This technology is HIPAA compliant, meaning your information is protected by the same privacy and security rules as traditional medical records. The Al-generated documentation is reviewed and approved by your physician before being added to your official medical record. All data used by the AI scribe is deleted from its servers immediately after documentation is complete and added to your secure record.

Telehealth Consent

Telehealth involves remote medical consultations using electronic communications for services like evaluation, diagnosis, and treatment. Consultations will be through secure and encrypted platforms, and you must ensure you have a private and secure location for the session. Telehealth consultations may be recorded for documentation, quality assurance, or educational purposes. The same confidentiality standards apply to recorded sessions. You must notify the provider promptly if any technical issues affect communication or quality of care. Limitations & Risks: It cannot include physical examinations. There are potential risks like technical failures, interruptions, or security breaches. Your physician will determine if telehealth is appropriate for your specific condition.

Acknowledgment of Privacy Practices (HIPAA)

You have certain rights to privacy regarding your protected health information under HIPAA. Your health information will be used for your treatment, to obtain payment from third parties, and for normal healthcare operations (like quality assurance You have the right to review and copy your health information and request changes if you believe it's incomplete. You can also request in writing to restrict how your information is used or disclosed, though the facility may not always accept these restrictions.

Patient Acknowledgment and Signature

By signing below, I confirm that I have read, understood, and agree to the terms outlined in this Patient Consent & Acknowledgement Form.

Printed Patient Name

Date

Signature of Patient or Representative

If Representative Name and Relationship to Patient

Houston Gastro Institute

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

AUTHORIZATION TO RELEASE OR OBTAIN HEALTH CARE INFORMATION

Patient Consent & Acknowledgment Form