GASTROINTESTINAL SPECIALISTS Aria Torresdale Medical Office Bldg. Barix Clinic 3998 Red Lion Rd S.242 280 Middletown Blvd Philadelphia, Pa 19114 Langhorne, Pa 19047 215-632-3500 215-702-7090
UPPER GASTROINTESTINAL ENDOSCOPY PREPARATION
YOU ARE SCHEDULED FOR A GASTROSCOPY ON ____________________ DO NOT TAKE ANY FOOD OR LIQUID BY MOUTH AFTER MIDNIGHT THE NIGHT BEFORE YOUR PROCEDURE. YOU MAY TAKE MEDICATIONS FOR BLOOD PRESSURE AND THE HEART WITH A SIP OF WATER THE MORNING OF THE PROCEDURE. ANY DENTURES MUST BE REMOVED BEFORE THE PROCEDURE. IT IS VERY IMPORTANT THAT YOU ARRANGE TO HAVE SOMEONE DRIVE YOU HOME AFTER THE PROCEDURE, AND THAT YOU DO NOT WORK OR DRIVE FOR THE REMAINDER OF THE DAY. PATIENTS ARRIVING WITHOUT A RIDE WILL HAVE THEIR PROCEDURE RESCHEDULED. IF YOU TAKE ANY BLOOD THINNING MEDICATIONS (ASPIRIN, ECOTRIN, ADVIL OR MOTRIN ETC.) ANTIPLATELET (COUMADIN, AGGRENOX, PLAVIX) OR ARTHRITIS MEDICINES (VIOXX, CELEBREX), PLEASE NOTIFY YOUR DOCTOR OR CARDIOLOGIST. THESE MEDICATIONS MUST BE STOPPED FOR 5 YO 7 DAYS PRIOR TO THE PROCEDURE. IF YOU HAVE ANY QUESTIONS, PLEASE CALL OUR OFFICE AT:
**IT IS EXTREMELY IMPORTANT THAT YOU BRING ALL PRESCRIPTION MEDICATION BOTTLES, YOUR INSURANCE CARD AND ANY CO-PAYS/CO- INSURANCES WITH YOU ON THE DAY OF YOUR PROCEDURE** GASTROINTESTINAL SPECIALISTS Aria Torresdale Medical Office Bldg. Barix Clinic 3998 Red Lion Rd S.242 280 Middletown Blvd Philadelphia, Pa 19114 Langhorne, Pa 19047 215-632-3500 215-702-7090
IMPORTANT INFORMATION REGARDING YOUR INSURANCE Dear Patient: Should your doctor determine that you require a diagnostic endoscopy (upper endoscopy and/or colonoscopy); your procedure will be performed in the Gastrointestinal Specialists Ambulatory Surgical Center. The Ambulatory Surgical Center is approved by Medicare, licensed by the Commonwealth of Pennsylvania and accredited by the Joint Committee on Accreditation of Health Care Organizations. The Ambulatory Surgical Center is an outpatient facility, therefore, your insurance carrier will be billed a facility fee and any outpatient deductibles and/or co-pay for your individual insurance plan will apply. If you are uncertain of your policy deductibles, please contact your insurance carrier for this information. You will be responsible for the deductible and co-pay. These will be due at time of service. For the comfort and safety of patients undergoing endoscopic procedures, physicians and nurse anesthetists employed through Anesthesia Advantage of Newtown, PA. provide conscious sedation during the endoscopic procedure. Anesthesia Advantage will bill your insurance carrier and deductibles and/or co-pays will apply. Patients without insurance will be required to make financial arrangements prior to performance of procedure. Thank you. Billing Dept. - Gastrointestinal Specialists, Inc. 610-664-9730 or 9731 Billing Dept. - Anesthesia Advantage 215-860-4110 GASTROINTESTINAL SPECIALISTS Aria Torresdale Medical Office Bldg. Barix Clinic 3998 Red Lion Rd S.242 280 Middletown Blvd Philadelphia, Pa 19114 Langhorne, Pa 19047 215-632-3500 215-702-7090
Patient Name: ____________________________________________ Patient Date of Birth: _______/_______/_______ Date of Procedure: _______/_______/_______ In order to maintain compliance with the Pennsylvania Human Relations Act of 1955 and Title VI of the Federal Civil Rights Act of 1964, the Ambulatory Surgical Center is asked to prepare documentation of the following information regarding patient visits. Answers to the following questions are entirely voluntary on the part of the patient. Racial Background: _______________________________________ Religious Preferences: _____________________________________ Decline to Answer: ________________________________________
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