Your Visit & Patient Forms
Getting Ready for Your Visit to Rochester Colon & Rectal Surgeons
In order for us to provide the best care for you, it is very important that you bring the following items to your visit:
- A list of your current medications
- Any and all x-rays films
- Insurance information and card
- Information about what treatments and medications have been tried in the past
- Medical records from prior visits that you think may be helpful
- A written list of questions to help you remember any question you need to discuss with your colorectal specialist
- If your insurance requires a referral, please contact your Primary Care Provider for the referral
- New Patients: download a patient registration below
Please arrive 20 minutes before your scheduled appointment so we can collect and review any paperwork you have provided.
Office/surgery/colonoscopy appointments are scheduled between 8:30 – 11:30 and 1:00 – 4:30pm
Telephone calls between 8:30 – 5:00pm. We also offer colonoscopy appointment’s on Saturday mornings.
UNDERSTAND YOUR HEALTHCARE RESPONSIBILITY:
Healthcare can be confusion. There are many different terms that make it difficult to understand what you are responsible to pay. Here are four commonly used healthcare insurance terms from Healthcare.gov to better understand your healthcare financial responsibility:
The amount you pay for covered healthcare services before your insurance plan starts to pay. For example if you have a $2000 deductible plan YOU will pay the first $2000 of covered services yourself. After your deductible is met, you may need to continue to pay copayment or coinsurances for covered services.
A fixed amount ($40, for example) you pay for covered healthcare services. You may need to pay copayment after your deductible has been met. Copayment amounts vary for different type of services; such as prescription drugs, lab test, x-rays, office visits and surgeries. It is wise for you to understand what your copayment amount is for different services.
The percentage of costs of a covered health care service you pay (20% for example), after you have paid your deductible.
Let’s say for example your health plan allowed amount for an office visit is $100 and your coinsurance is %20 you will be responsible pay $20. BUT if you have not met your deductible you will need to pay the full amount of $100.
OUT – OF – POCKET MAXIMUM/LIMIT:
The most you are responsible to pay in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the cost of covered benefits.
The out-of-pocket limit doesn’t include your monthly premiums. It also doesn’t include anything you spend for services your plan doesn’t cover.
For all office visits, payment is required at time of service. Co-pays, deductibles and or coinsurance for those patients with Medicare or one of our contracted managed care plans are also required at the time of your visit. If you have a deductible be prepared to pay $75 at the time of your visit, this will be a “down payment” for whatever services rendered and you will be balance billed for the remaining amount.
Additional charges may be generated for procedures and tests. The providers at RCRS will bill your insurance carrier for expected payment. You will be responsible for any deductible and/or co-pay amount.
As colorectal specialists it is very likely that your provider will perform a diagnostic procedure essential in managing your medical condition. These procedures are known as anoscopy, proctoscopy, and/or a flexible sigmoidoscopy. Your insurance carrier may define them as a “surgical procedure”. Your explanation of benefits may reflect the use of this term and you may be charged an additional co-payment or deductible for these procedures.
If it is determined that surgery is necessary, we will coordinate payment arrangements for any procedures your insurance company determines is your responsibility.
Secure Online Patient Forms
The following forms can be filled out online:
Download Patient Forms
To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com. Please bring your completed forms with you to our office at the time of your visit.
If you are a new patient or established patient that has not been seen in 3 years please print the Patient Intake Forms. This packet includes all the forms needed prior to your office visit.
Office forms and policies
- Patient Authorization for Medical Records Release
- Cancer Family History Questionaire
- HIPAA Notice of Privacy
- HIPAA Privacy Consent Form
- Nurse Intake Form
- Financial Responsibility Form
Our office is participating in the Greater Rochester Regional Health Information exchange (RHIO). You will be asked to complete the consent form to either Give or Deny consent to the RHIO when you arrive at your appointment.
If you have questions about the RHIO you can contact them at 1877-865-RHIO(7446) or online at www.GRRHIO.org
These listed preparation instructions are intended for use before a procedure such as colonoscopy, colon surgery, etc.; an RCRS provider will be prescribing the type and timing of each individual’s prep, do not start unless instructed. Call if you have any questions if or when you should be taking a prep prior to your visit.
Colonoscopy Prep Instructions and Consent
- Miralax morning exam prep
- Miralax afternoon colon prep
- MoviPrep morning exam
- Moviprep afternoon exam
- PEG morning exam prep
- PEG afternoon exam prep
- Medication Guide for in Office Procedures
- Consent for Colonoscopy
Bowel Surgery Preparations