American Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Pacific IslanderWhite/Non-HispanicOtherUnknown
Emergency Contact Number:
Primary Care Provider or Referring Provider:
Pharmacy & Preferred Location:
Policy Holder Name:
Policy Holder DOB:
Person Responsible for Bill if other than above:
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. I authorize my insurance company(ies) 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.
Reason for Visit:
Cancer & Type:
Drinks per week
Beers per week
Cigarettes per day
# of years
# of years quit
History of Injectable Drug Use
Marijuana Use, Frequency, & Form :
Have you ever had:
List your Operation & Operation year
Enter text here...
Reason for hospitalization & Hospitalization year
Enter text here...
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.
Enter text here...
Enter text here...
Recent Weight Change
Ringing in Ears
Yes No Defibrilator
Cardiac Valve Disease
Shortness of Breath
Swelling of Ankles
Do you take blood thinners?
Do you take Aspirin, Naprosin or Advil?
Coughing up Blood
Nausea or Vomiting
Change in Bowel Habits
Black, Tarry Stool
Memory Loss / Confusion
Heat or Cold Intolerance
Excessive Thirst / Urination
We respect your right to privacy regarding medical information. May we Share information with your Spouse?
If so, Their Name:
We understand that you may have concerned relatives. Pleaselist names of Adult children, other family members and/or contact persons with whom we may share information without addition written consent:
Name / Relationship / Contact Number:
Additional Information you wish to share:
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.
Patient legal Representative (if applicable):
Name of Representative:
Relationship to Patient:
Definition: A legal document giving a person the power to make decisions for another person, (e.g. current medical decisions, financial decisions).
Do you have a power of attorney on file? Yes No
Name of person who holds Power of Attorney:
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:
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.
I, , 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.
My cell phone:
Leave a message? (Y/N)
My home answering machine:
My office/work voicemail:
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.)
Upload Patient ID and Insurance Card(s)
A. Notifier: Alaska Digestive and Liver Disease
B. First Name:
C. Identification Number:
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
G. OPTIONS: Check only one box. We cannot choose a box for you.
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.
If you have been web enabled please use the patient portal link below to communicate with staff and or physician(s).
Go to Patient Portal