Seguros y Facturación
Authorizations, Consents, and Policies
The documents below are online copies of the forms you have signed for your visit. These records are available for your reference. If you would like a printed copy of any signed form, please feel free to request one from our front desk at any time.
Patient Financial Policy:
Outlines our billing and payment expectations, including insurance coverage and co-pays, to ensure transparency in financial responsibilities.​​​​​
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Acknowledgment of Receipt of Our Privacy Practices Notice
Confirms that you have received information on how we protect and use your personal health information.
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Acknowledgment of Receipt and Agreement to Policies and Authorizations
Verifies that you have reviewed and agree to our key policies, including privacy, financial, and consent policies.
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Assignment of Benefits and Billing Authorization
Authorizes us to bill your insurance directly and receive payments for services provided on your behalf.
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General Consent of Care and Treatment
Provides your consent for our healthcare team to perform necessary treatments as part of your care.
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SWGA Office Policies
Summarizes important office policies, including appointment scheduling, cancellations, and general guidelines for visits.
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HIPAA Notice of Privacy Practices
Details your rights under HIPAA regarding the privacy and security of your personal health information.
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Informed Consent for Artificial Intelligence Scribe
Grants your consent to use AI technology during your visit to help document and summarize the patient's office visit. This AI tool assists healthcare providers with note-taking to ensure accuracy and improve your care experience.
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Online Forms
Medical Record Release Form: ​
Patients may request an electronic copy of their records by filling out an online Medical Record Release Form or submitting a request via our patient portal to receive a mailed paper copy of their records. We may call you to answer some security questions and verify your identity. Learn more medical records requests. ​​​​​
Authorization to Discuss Information:
​The Authorization to Discuss Medical and Financial Information form lets you designate specific individuals to receive updates about your healthcare and billing. By completing this form, you control who can access your medical and financial details to assist with treatment, appointments, or billing matters. You can cancel it at any time for your privacy and convenience.​​​​
Open-Access Colonoscopy
Our open-access colonoscopy service allows eligible patients to schedule their colonoscopy directly without needing a preliminary visit to a specialist. This option is designed to save you time and streamline access to this essential screening, which is key for the early detection and prevention of colorectal health issues.
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To determine if open-access colonoscopy is the right option for you, we ask that you complete a brief colonoscopy intake questionnaire. This form includes questions about your health history, any existing medical conditions, and family history of colorectal issues. It’s important to answer these questions honestly for your safety, as any undisclosed information may still become apparent during the procedure. Your transparency helps us prepare appropriately and ensure the safest, most effective care.
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If you have any questions about the intake form or the open-access process, please don’t hesitate to reach out—we’re here to make this experience as convenient and seamless as possible.
New Patient Form
To help us provide you with the best possible care, we ask that all new patients complete our New Patient Form before their first visit. This form gathers essential information about your health history, current medications, allergies, and any specific health concerns or goals you may have. By filling it out accurately, you help us prepare for your visit and ensure our team has a complete picture of your health needs from day one.