Dear Patient:

            Thank you for making your appointment with Dr. Chodos.

            Enclosed you will find a Patient Information Sheet, Financial Agreement and Patient Questionnaire. Please fill out these forms and mail them back to our office prior to your initial visit. Also, please read and sign our financial agreement from and mail it back with the others. You can keep one copy for your files. These forms are to help facilitate your visit with us and to help us serve you better.

            Please carefully read each sheet and if you have any questions regarding the enclosed forms, please call the office at the number listed above. We will be happy to help answer any questions that you may have.

            Also, when coming to the office for your initial visit, please bring your insurance card(s) with you, as we need to make copies of them. It is a policy at our office to only bill the primary insurance, but some exceptions are made. If you have Medicare and an approved Medigap second insurance, the Medigap will automatically be billed.

            At each visit copayment is due at the time of your visit depending on your insurance policy, etc. If you have a deductible to meet, you will be expected to pay the fee for the visit at the time of the visit depending on the amount owed towards the deductible. This can be checked with your insurance company prior to your visit. Please read the Financial Form for more insurance and payment information.

            On the day of your initial visit, please know which lab and radiology (x-ray) facility your insurance requires you to use.

            If you are scheduled for an appointment and need to cancel, please call at least 24 hours (one business day) in advance of the appointment or there will be a $25 cancellation fee to pay.

            If you have had a GI x-ray (Upper GI, Barium enema, Abdomen sonogram or Abdomen CT scan) in the past, please bring the x-ray report with you to your appointment. If you had labs done that you want us to see bring the report or tell us where labs done in advance of visit so we can get them. This is very important.

            Your cooperation in these matters is greatly appreciated.

Rev. 9/13