Phone:  (907) 569-1333
Fax:  (907) 569-1433

Patient Portal

Direct Access Colonoscopy Program

Welcome to the Direct Access Colonoscopy Program

We are pleased that you have chosen ADLD as your Gastroenterology provider. You and your primary care provider have determined that you need a colonoscopy. Colonoscopy is a medical procedure during which a flexible tube is used to look inside the colon.

The Alaska Digestive and Liver Disease Clinic strives to provide compassionate and high quality medical care to patients. Please note that without a full consultation it is possible that there are gastrointestinal issues that may not be addressed in the direct access program. If you would rather see the gastroenterologist in consultation we will provide you with an appointment. For a direct access colonoscopy, you will not meet the gastroenterologist in person until the day of your procedure.

You have been identified as having minimal medical problems which do not require a consultation to review. We ask that you complete our patient packet and submit it prior to being scheduled for your procedure. After your information is received and reviewed ,our office staff will call you to schedule your procedure and give you bowel preparation instructions. 

Please note that some insurance carriers do not cover colonoscopy as a screening procedure for colorectal cancer. You should check with your insurance carrier to confirm coverage and benefits. We are happy to provide procedure and diagnosis codes at your request for you to provide to your insurance company. To assist us in providing you with the correct information,

By typing you name here, you are signing this application electronically. You agree you electronic signature is the legal equivalent of your manual signature on this application

 
 

Please make sure to fill out the Patient Registration Form Below

Patient Information








 




 





 




 




 





 
 
Primary Insurance









 
 
Secondary Insurance









 
 
Tertiary Insurance









 
 
 


Patient is responsible for all fees regardless of medical coverage. It is customary to pay at the time of service unless other arrangements have been made in advance. I authorize Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D. to administer medical treatment.

 

I authorize Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., 3851 Piper Street, Suite U466, Anchorage, AK 99508 to release any medical information required by my insurance company or Worker’s Compensation carrier for the processing of all medical claims on my behalf. and to pay benefits directly to Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., 3851 Piper Street, Suite U466, Anchorage, AK 99508 for claims on my behalf. I agree to promptly sign over any checks that I receive within 7 days of receipt. I understand that those charges not covered by my insurance company are my own responsibility, and there is a monthly charge of 1% on the account over 90 days. In the event that my insurance company pays Ronald J. Boisen, M.D., Daryl M. McClendon, M.D. and/or Jeffrey W. Molloy, M.D., a fee which I have already paid, I understand that I will be promptly reimbursed.

Health History


Family Health History

Relative/s with:







 
Personal Social History


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Smoking
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History of Injectable Drug Use
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Previous Procedures


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Past Medical/History Problems
 


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Hospitalization and Surgery
Surgery


Hospitalization


 


List all medicines, birth control pills, or vitamins you take with or without a prescription including over the counter drugs. (e.g. Aleve, Tagamet 200. etc) Include herbs and aspirin. Please incude doses and frequency.


 
Review of Systems
for the Last 12 months
Constitutional


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Eyes


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Ears / Nose / Mouth / Throat


Yes No

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Cardiovascular


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Respiratory


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Skin


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Hematological


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Gastrointestinal


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Neurological


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Psychiatric


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Endocrine


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Your Right to Privacy

We respect your right to privacy regarding medical information. May we Share information with your Spouse?

If so, Their Name:

Contact Number:

 

We understand that you may have concerned relatives. Please

I authorize RONALD J. BOISEN, M.D, DARYL M. MCCLENDON, M.D. and/or JEFFREY W.MOLLOY, M.D. to access my electronic prescription records for continued care and further treatment.

I Acknowledge and agree that I have received a copy of RONALD J. BOISEN, M.D, DARYL M. MCCLENDON, M.D. and/or JEFFREY W.MOLLOY, M.D. notice to Privacy Practices. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

 

 
Power of Attorney

Definition: A legal document giving a person the power to make decisions for another person, (e.g. current medical decisions, financial decisions).

Yes No

 
Appointment and Procedure Cancellation Policy

I understand that RONALD J. BOISEN, M.D; DARYL M. MCCLENDON, M.D. and JEFFREY W.MOLLOY, M.D. reserve the right to the following in the event that you need to reschedule:

  • $25.00 Charge for cancelled office visit without giving at least one (1) business days’ notice
  • $50.00 Charge for cancelled procedures without giving at least two (2) business days’ notice. This allows other patients to be scheduled into that appointment slot. It also makes it possible to reschedule your appointment more efficiently.

I have read, acknowledged and agree to the terms above.By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Phone Message Consent Form

, , acknowledge and agree that (Alaska Digestive and Liver Disease) and any affiliates or vendor thereof, including collection or billing companies, may contact me by email, telephone or text message to any telephonic number or email address I have provided to you, and any other telephone number associated with my account, including wireless or mobile telephone numbers. I further agree that you may use any method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) or prerecorded message. I also agree that I will notify (Alaska Digestive and Liver Disease) if I have given up ownership or control of any such telephone number.

 

 

 

 

 

Medicare Long Term Authorization

I request that payment of authorized Medicare Benefits be made on my behalf for any service furnished to me by Ronald J. Boisen, MD, Daryl M. McClendon, MD and/or Jeffrey W. Molloy, MD. I authorize any holder of medical or other information about me release to the Health Care Financing Administration and its agents any information needed to determine these benefits for related services.

(Authorization good for one year from the date signed.)

Advance Beneficiary Notice of Non-Coverage

Upload Patient ID and Insurance Card(s)

 

A. Notifier: Alaska Digestive and Liver Disease

B.

 

C. Identification Number:

Advance Beneficiary Notice of Noncoverage

NOTE: If Medicare doesn't pay for the D. Office Visit below, you may have to pay.

Medicare does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We accept Medicare may not pay for the Office Visit below.

D. OFFICE VISIT

E. REASON MEDICARE MAY NOT PAY:
Not indicated for diagnosis and/or treatment in this case

F. ESTIMATED COST
No More than $600

WHAT YOU NEED TO DO NOW:

  • Read this notice, so you can make an informed decision about your care.
  • Ask us any questions that you may have after you finish reading.
  • Choose an option below about whether to receive the D. Office Visit listed above.
    • Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS:

OPTION 1. I want the Office Visit listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2. I want the Office Visit listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I can not appeal if Medicare is not billed.

OPTION 3. I don't want the Office Visit listed above. I understand with this choice, I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

H. ADDITIONAL INFORMATION

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY:1-877-486-2048).

 

CMS does not discriminate in its program and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email: [email protected]

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn; PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. Signing below means that you have received and understand this notice. You will also receive a copy.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.