Delta Gastroenterology and Endoscopy Center
9140 HIGHWAY 51 N
SOUTHAVEN, MS.38671
662.820.8222 FAX 662.280.5541
WWW.deltagastro.net
Patient Information
Name *
Email *
DOB
MM
/
DD
/
YYYY
Address
City/St/Zip code *
SSN *
Driver Licence no
Marital Status:
Clear selection
Telephone Number : Home
Cell
Employer
Occupation
Work
Work Address
St/Zip
Primary care Physician
Referring Physician
Were symptoms caused by an accident?
Clear selection
If YES give date and description of the accident
Please give the attorney’s name and contact information (if applicable)
Name:
Office Number:
Emergency Contact Information
Name
Relationship
Phone
Address
City
Primary Insurance Information
Insurance Company Name
ID Number
Subscriber Name
Group Number
Employer
Secondary Insurance Information:
Insurance Company Name
ID Number
Subscriber Name
Group Number
Employer
Authorization and Assignment: I hereby authorize insurance payment or any other settlement on my behalf to be paid directly to Delta Gastroenterology and Endoscopy Center P.C. I acknowledge I am financially Responsible for non-covered fees or service, interest, attorney fees or legal fees incurred. I also authorize the release of medical information.A representative of this office is authorized to provide information on my behalf in response to my request regarding services incurred. This assignment may be photocopied and is non-avoidable. I also authorize that all the necessary services and methods be rendered by Delta Gastroenterology and Endoscopy Center, P.C.
I hereby give my permission for this office to leave message on the answering service/voicemail/text messaging at:
Home
Cell
Office
Text
Permission Given to:
Relationship
PLEASE READ ALL THE SECTIONS BELOW. IF YOU HAVE ANY QUESTION, PLEASE ASK OUR STAFF BEFORE SIGNING.
Do you have any of the following advance directives?
Living will
Clear selection
Do not resuscitate
Clear selection
Durable Power of Attorney
Clear selection
Health Care Policy
Clear selection
Do you want information regarding advance directives?
Clear selection
Information given by
Name
PATIENTS RIGHTS (I have read and received the patient’s rights. PREFERENCE)
Do you have any religious or culture preference that may interfere with your treatment protocol?
Clear selection
If yes, please explain
Authorization for release of medical information
Patient’s name
DOB
MM
/
DD
/
YYYY
SSN
Address
City/State/Zip Code
Phone number
Date of Request
MM
/
DD
/
YYYY
Date Needed
MM
/
DD
/
YYYY
❏ I authorize Delta Gastroenterology/Endoscopy Centre to release Information to
Name of provider of facility
Address
City, State, Zip Code
Phone Number, Fax Number (Include area code)
❏ I authorize Delta Gastroenterology/Endoscopy Centre to obtain Information from
Name of provider of facility
Address
City, State, Zip Code
Phone Number, Fax Number (Include area code)
TYPE OF RECORDS REQUESTED
All medical records related to a specific illness or injury
Specify illness/injury:
Date(s) of treatment
MM
/
DD
/
YYYY
Specific information (Tick one or more, as applicable)
Select
Procedure report
X-ray reports
History and physical
Physical therapy
Laboratory test results
Clear selection
Notice of Privacy Practice (Effective Date: April 14, 2003)
I have carefully read this notice of privacy practices.
Date
MM
/
DD
/
YYYY
Print Name
FINANCIAL POLICY
Delta Gastroenterology & Delta Endoscopy Center, P.C. would like to inform you of the charges for your procedure. You could receive up to five different bills for services rendered in our facility.
1. Delta Gastroenterology – Physician Charge
2. Delta Endoscopy Center – Facility Charge
3. SOMS Anesthesia – Anesthesia Charge
4. Delta Gastroenterology – Pathology Charge (if a biopsy is taken)
5. APS (Advanced Pathology Solutions) – Pathology Charge (if a biopsy is taken)
6. Self –Pay Pathology Fee 45.00 per biopsy
*PLEASE CONTACT YOUR INSURANCE TO ENSURE WE ARE IN YOUR NETWORK *
Co-pays and Deductibles
These payments are due at the time of services rendered. If you are unable to meet the financial terms, and other arrangements have not been made prior to your scheduled appointment date, you will be asked to reschedule your appointment. Medicare patients are responsible for 20% if there is no secondary insurance carrier. For commercial insurance accounts, payment is expected from you or your insurance carrier within 30 days from the date of service. We accept Cash, Visa, Mastercard, American Express, Discover and Care Credit. Please contact our billing office at 662-280-8222 regarding Care Credit.
Self-Pay
These payments are due at the time of services rendered unless other arrangements have been approved. If paying with

• Payment: Two separate payments will be needed. $600.00 will be issued to Delta Endoscopy Center for the Facility fee and $250.00 made out to SOMS Anesthesia.
• Credit Card: Your credit card will be ran twice. Once for Delta Endoscopy Center for $600 and once for SOMS Anesthesia for $250.00.
• If a biopsy it taken, Pathology charges will apply from Delta Gastroenterology and GI Pathology. Please call Billing for more information on potential costs and information. These charges are not included in the $850.00 payment and are separate charges incurred. As a courtesy to you, we offer payment plans for these charges.

If you do not receive an explanation of benefits from your insurance carrier within 30 days, it is your responsibility to begin payment. Also, you will need to contact your insurance carrier for the exact status of all the charges and to provide this office with the current information. Accounts are considered delinquent when there is no payment activity every 30 days and will be reviewed for collection processing.
Print Name
Date
MM
/
DD
/
YYYY
Brief Assessment Model that Conforms to the Joint Commission on Accreditation of Healthcare Organizations' Spiritual Assessment Recommendations
Is spirituality or religion important to you?
Clear selection
Does spirituality help you in dealing with your problems?
Clear selection
Do you attend a church or some other type of spiritual community?
Clear selection
Are there any spiritual needs or concerns I can help you with?
Clear selection
Would it be okay for me to pray with you?
Clear selection
Date
MM
/
DD
/
YYYY
Time
Time
:
PATIENT FINANCIAL POLICY
Thank you for choosing Delta Gastroenterology and Endoscopy CenterPCas your health care provider. We are committed to building a successful physician-patient relationship with you. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc.).
Co-pays
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due at time of check-in unless previous arrangements have been made with a billing coordinator. We accept Cash, Visa, Mastercard, American express, Discover or Care Credit. Please contact our billing department at 662-280-8222 to discuss Care Credit.
Payment Plans
If you have negotiated a payment plan with us, you are responsible for making timely and consistent monthly payments. We offer payment plans as a courtesy to our patients in time of need. If you fail to keep your scheduled due date, your account will be sent to collections for non-payment. Please contact our billing department to set up a payment plan 662-280-8222.
Insurance Claims
Insurance is a contract between you and your insurance company. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.
Referrals and Pre-authorizations
Certain health insurances (HMO,POS, etc.) require that you obtain a referral or prior authorization from your Primary Care Provider (PCP) before visiting a specialist. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower or no payment from the insurance company, and the balance will be your responsibility. Alternative payment arrangements or rescheduling of your appointment may be necessary if not obtained.
Self-pay Accounts
Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in which our practice does not participate, or patients without an insurance card on file with us. It is always the patients’ responsibility to know if our office is participating with their plan. If there is a discrepancy with our information, the patient will be considered self-pay unless otherwise proven.

Self-pay patients will be required to pay $225.00 at the initial appointment. Established patient appointments will be required to pay $125.00. Payment arrangements are available if needed. Please ask to speak with a billing specialist to discuss a mutually agreeable payment plan. It is never our intention to cause hardship to our patients, only to provide them with the best care possible and the lease amount of stress
Outstanding Balance Policy
It is our office policy that all past due accounts be sent two statements. If payment is not made on the account, a single phone call will be made to try to make payment arrangements. If no resolution can be made, the account will be sent to the collection agency, or attorney, and possible discharge from the practice. In the event an account is sent to collections, the person financially responsible for the account will be responsible for all collection costs including attorney fees and court courts.

Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other personal party.

This financial policy helps the office provide quality care to our valued patients. If you have any questions or need clarification of any of the above policies, please feel free to speak with the billing office.


DELTA GASTROENTEROLOGY AND ENDOSCOPY CENTER P.C. RESERVES THE RIGHT TO CHANGE AND/OR MODIFY THIS INFORMATION AT ANY TIME.
Patient Name
Date
MM
/
DD
/
YYYY
Signature
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy