If no referring or primary care provider, please write “none.”
Please list the name of the practice. If you do not have a referring or primary care office, write “none.”
Who are we allowed to contact in the event you are unavailable?
Re: Procedure Confirmation & HIPAA Compliance
It is important that patients 65 and older have a history and physical on file with their primary care physician within 30 days of their Open Access Colonoscopy. This can easily be obtained through your primary care provider.
Please check Yes or No in answer to the following medical history questions.
Upon clicking Send, this form will be sent to Charlotte Gastroenterology & Hepatology for processing. If there are no contraindications, you will be assigned to one of our physicians and scheduled for a colonoscopy. If medical concerns are identified, we may need to schedule an office visit before scheduling a colonoscopy. Your insurance company will be notified for benefit verification. We will contact you within 10 days of receipt of this form. If you have not heard from our office within 10 days, please call (704) 717-5548 and ask for the Open Access Triage Coordinator.