Patient Forms and Consents

Financial Policy

When seeking medical treatment, we feel that patients should not only understand their medical condition, but also their financial liability. We are here to aid in your financial claim processing, but ultimately it is the patient’s responsibility to pay outstanding balances.

We thank you in advance for taking the time to review these policies and appreciate your compliance and cooperation.

Please feel free to discuss any concerns or questions you may have with our billing staff.

Things to bring with you to your visit:

Health Insurance Card (will be checked at every visit)
Drivers License
Method of payment – for your convenience we accept cash, check, debit and credit card.
The credit cards we accept are Visa, Master Card and Discover.

Patient out of pocket expenses:

We are obligated to collect the co-pay at the time of your visit. This is a requirement of your insurance plan. Your copay will be collected when you check in.
Any co-pays not paid at time of service are subject to a $10 billing fee.
All payments are due at the time of service.
For self-pay, deductible, or other large amounts we offer Care Credit, credit cards or monthly payment plans for your convenience.

Patient Responsibility:

It is the patient’s responsibility to provide EPGI with the most up to date insurance information.
It is also the patient’s responsibility to verify benefits of their policy
We are not liable for any misquoted benefit information. You are fully responsible for verifying benefits of your policy.

Self-Pay:

We offer a reasonable discount for cash pay/fee for service patients who have no health insurance coverage.
Payment in full is expected at the time of visit unless prior arrangements have been made with the billing department.
You will be asked to sign a waiver stating that you have no health insurance coverage and will not be filing a claim with any health insurance carrier or third party payer.
We understand you may be applying for Medical Assistance (MA) to help defray these costs. We will expect monthly payments on your account until you can prove you have been enrolled for coverage with MA. Any monies collected for services rendered after your eligibility date will be refunded. You are responsible for informing us when you become active with MA.

HMO plans:

A valid referral is required at the time of service prior to being seen. This is a requirement of your insurance plan.
If you do not have a referral at the time of your visit, you will be asked to sign a waiver stating you are aware that you are responsible for payment upon check out on that day or you will need to reschedule your appointment.
If a valid referral is obtained and your insurance company reimburses EPGI, you will be refunded all monies due.

Litigation cases:

We do not get involved with any litigation accounts, disputed work comp cases, divorce decrees or auto accidents. You will be 100% responsible for any balances due.

Returned checks:

There is a $25 fee for all returned checks.
Payments after a returned check are cash or credit card only.

Credit card payment plan policy:

You will be asked to review and sign our credit card on file policy and authorization form.
Your credit card will be billed for fees not covered by your insurance and according to the agreed upon monthly payment plan.

Outstanding balances/Collections:

Prior to providing additional services to you, payment in full of total outstanding balances will be required.
Patients with two or more delinquent accounts, or delinquent accounts greater than $500, will be discharged from the practice.
Billing statements will be mailed for balances that are denied or deemed patient responsibility. Payment is expected within three weeks of the billing date. If no payment has been received a second statement will be sent. In the event a third statement is required, additional collection steps will be taken. Your failure to make payment may result in your account being turned over to a third party collection agency who reports to the credit bureau.

Refunds:

Refunds are issued to the appropriate party. Patient refunds will not be processed until all active or past due charges are paid in full. Refunds of less than $5 will not be issued until requested.

EPGI complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or gender.

Patients' Rights and Responsibilities

PATIENTS’ RIGHTS AND RESPONSIBILITIES

A patient has the right to respectful care given by competent personnel.
A patient has the right, upon request, to be given the name of his attending practitioner, the names of all other practitioners directly participating in his care, and the names and functions of other health care personnel having direct contact with the patient.
A patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination and treatment are considered confidential and should be conducted discreetly.
A patient has the right to have records pertaining to his/her medical care treated as confidential except as otherwise provided by law or third party contractual arrangements.
A patient has the right to know what Center rules and regulations apply to his/her conduct as a patient.
A patient has the right to expect emergency procedures to be implemented without unnecessary delay.
A patient has the right to good quality care and high professional standards that are continually maintained and reviewed.
A patient has the right to full information, in lay terms, concerning diagnosis, treatment and prognosis, including information about alternative treatments and possible complications. When it is not medically advisable to give the information to the patient, the information shall be given on his behalf to the patient’s next of kin or other appropriate person.
Except for emergencies, the physician shall obtain the necessary informed consent prior to the start of any procedure or treatment, or both.
A patient or, in the event the patient is unable to give informed consent, a legally responsible party, has the right to be advised when a physician is considering the patient as part of a medical care research program or donor program, and the patient or legally responsible party must give informed consent prior to actual participation in such program. A patient or legally responsible party may, at any time refuse to continue in any such program to which he has previously given informed consent.
A patient has the right to refuse drugs, treatment, or procedures offered by the Center, to the extent permitted by law, and a physician shall inform the patient of the medical consequences of the patient’s refusal of drugs, treatment or procedures.
A patient has the right to medical and nursing services without discrimination based upon race, color, religion, gender, sexual preference, national origin, or source of payment.
A patient who does not speak English shall have access, where possible, to an interpreter.
The Center shall provide the patient, or patient designee, upon request, access to the information contained in his medical records, unless the attending physician for medical reasons specifically restricts access.
A patient has the right to expect good management techniques to be implemented within the Center considering the effective use of time of the patient and to avoid the personal discomfort of the patient.
When medically advisable, a patient may be transferred to another facility. He/she or his next of kin or other legally responsible representative will be provided with complete information and an explanation concerning the needs for and alternatives to such a transfer. The institution to which the patient is to be transferred must first have accepted the patient for transfer.
A patient has the right to examine and receive a detailed explanation of his bill.
A patient has the right to be informed of his rights at the time of admission, and be given a copy of the Patient’s Rights and Responsibilities when admitted to the facility.
Receive as much information about any proposed treatment or procedure as he/she may need in order to give informed consent or to refuse the course of treatment.
Participate in the development and implementation of his/her plan of care and actively participate in decisions regarding his/her medical care. To the extent permitted by law, this includes the right to request and/or refuse treatment.
Be advised of the policy on Advanced Directives, and Living Wills in the facility.
Be advised of the facility’s grievance process, should he/she wish to communicate a concern regarding the quality of the care he/she received. Notification of the grievance process includes: who to contact to file a grievance and that he/she shall be provided a written notice of the grievance determination.
The patient shall have appropriate assessment and management of pain.

Patients Responsibilities

Patients are expected to:

Provide accurate and complete information about their present complaints, past medical illnesses, hospitalizations, surgeries, medications, and other matters relating to their health.
Tell their health care providers whether they understand the treatment, plan of care, and what is expected of the patient.
Provide a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, if required by the provider.
Be responsible for keeping appointments and for notifying the facility or physician when he/she is unable to keep the appointment.
Be responsible for his/her actions should he/she refuse treatment or not follow physician’s orders.
Inform his/her provider about any living will, medical power of attorney, or other directive that could affect his/her care.
Accept personal financial responsibility for any charges not covered by his/her insurance.
Be respectful of all the health care providers and staff, as well as other patients.

You have the right to file a grievance with the State if you feel you have an issue the Endoscopy Center will not or cannot resolve. You may notify the following regulatory agencies:

Division of Acute and Ambulatory Care Office: 1-800-254-5164
Medicare Beneficiary Ombudsman: www.cms.hhs.gov/center/ombudsman.asp

Screening and Diagnostic Colonoscopy

Screening
Did you know that colon cancer is the third most commonly diagnosed cancer and the second leading cause of cancer death? And did you know that the average risk of being diagnosed is about one in 19?

Adults age 50 and older without any risk factors, and those with a family history of colon cancer, colon polyps, or inflammatory bowel disease should be screened every 10 years for colon cancer. Colon cancer can be prevented and is most easily treated when detected early.

At EPGI we are dedicated to the prevention and early detection of colon cancer and perform screening colonoscopies on a daily basis. Our highly trained physicians and clinical staff are available to answer any questions and walk you through the screening process. We have many valuable educational resources and perform the procedure in both the comfort of our outpatient ambulatory surgical center as well as the hospital setting.

Diagnostic

In addition to performing screening colonoscopy for the early detection of colon polyps and colon cancer, the physicians at EPGI perform diagnostic colonoscopy to help diagnose common gastrointestinal diseases.

If you’re experiencing gastrointestinal symptoms such as abdominal pain, rectal bleeding, diarrhea, blood in stool, constipation, unexplained weight loss, among other symptoms, you may be a candidate for a diagnostic colonoscopy.”

Diagnostic colonoscopies are performed by EPGI physicians at our endoscopy center, Lehigh Valley Hospital and Health Network – Cedar Crest, Lehigh Valley Health Network – Muhlenberg, and Sacred Heart Hospital.

Colonoscopy Preparation:

EPGI is pleased to have patterned with, yourPATIENTadvisor, a service that provides our patients with comprehensive colonoscopy preperations instructions, email and phone call reminders, and advisors who can help answer bowel preparation questions during extended hours when our office staff is not available.

Patients are automatically enrolled in the program when a colonoscopy is scheduled. From there, patients will receive either a welcome email or phone call (patients will not receive a phone call if an email address is provided) and a welcome letter in the mail which will arrive in a bright blue envelope. This welcomes patients to their patient advisor, provides contact information, and provides information about when, where, and with who their procedure is scheduled.

From there, patients will receive email and phone call reminders leading up to their procedure at:

4 weeks
14 days
7 days
3 days
1 day

A link to preparation questions is included in every email if an email address is provided. A paper copy of preparation instructions will be mailed to the patient’s home 14 days prior to their scheduled procedure. These instructions will also arrive in a bright blue envelope.

Any preparation questions leading up to the scheduled procedure should be directed to an advisor at (800) 349-0285 or
support@yourpatientadvisor.com.

Advisors are available:
Monday – Friday 7:00 am – 10:00 pm EST
Saturday 10:00 am – 6:00 pm EST
Sunday 12:00 pm – 8:00 pmEST

Advisors are available in both English and Spanish.

Click here to learn more about Colonoscopies.

Upper Endoscopy

Upper endoscopy enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain. Upper endoscopy is also called EGD, which stands for esophagogastroduodenoscopy.

For the procedure the physician will use a thin, flexible, lighted tube called an endoscope. You will be sedated during the exam. The endoscope transmits an image of the inside of the esophagus, stomach, and duodenum, so the physician can carefully examine the lining of these organs. The scope also blows air into the stomach; this expands the folds of tissue and makes it easier for the physician to examine the stomach.

The physician can see abnormalities, like inflammation or bleeding, through the endoscope that don’t show up well on x rays. The physician can also insert instruments into the scope to remove samples of tissue (biopsy) for further tests or treat bleeding abnormalities.

Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will probably have nothing more than a mild sore throat after the procedure.

The procedure takes 15 to 30 minutes. Because you will be sedated, you will need to rest at the endoscopy facility for 30 to 45 minutes until the medication wears off. You will need someone to drive you home after your procedure.

TIF Procedure for Reflux

TIF (transoral incisionless fundoplication) is the latest treatment for safely and effectively treating chronic acid reflux disease, also known as gastroesophageal reflux disease (GERD). A completely incisionless procedure, TIF reconstructs the antireflux barrier to provide a solution to the anatomical root cause of GERD. The procedure is for patients who are dissatisfied with current pharmaceutical therapies or are concerned about the long-term effects of daily use of reflux medications.

What is GERD?

If you have heartburn or reflux twice a week or more, you may have GERD. Heartburn is the most common symptom, but you may also experience:

Hoarseness or sore throat
Frequent swallowing
Asthma or asthma-like symptoms
Pain or discomfort in the chest
Sleep disruption (unable to sleep lying down)
Bloating
Excessive clearing of the throat
Persistent cough
Burning in the mouth or throat
Intolerance of certain foods
Dental erosions or therapy-resistant gum disease or inflammation

Normally, after swallowing, a valve between the esophagus and stomach opens to allow food to pass, then it closes to prevent stomach contents from “refluxing” back into the esophagus, causing a burning sensation in the chest. For people who suffer from GERD, the valve is dysfunctional and unable to prevent acid from refluxing into the esophagus.

TIF procedure

TIF was developed to emulate more invasive surgical techniques, but from within and completely without incisions and visible scars. Using the FDA-cleared EsophyX device, the procedure is performed through the mouth, rather than through an abdominal incision. Typically lasting no more than 50-60 minutes, the procedure is performed under general anesthesia and reconstructs the antireflux barrier to restore the competency of the gastroesophageal junction.

FAQ’s
Is the TIF procedure effective?

Studies show that for up to three years after the TIF procedure, GERD symptoms are reduced and most patients are able to stop taking PPI medications to control symptoms.

Is the TIF procedure safe?

The TIF procedure has an excellent safety profile. Clinical studies demonstrate that TIF patients rarely experience long term side-effects commonly associated with traditional antireflux surgery such as chronic dysphagia (trouble swallowing) gas bloat syndrome and increased flatulence.

Radio Frequency Ablation

Radiofrequency ablation (RFA) is used in the treatment of Barrett’s esophagus. During radiofrequency ablation treatment for Barrett’s esophagus, the doctor uses an endoscope to insert a thin tube or catheter down your esophagus. The catheter has a balloon at the end, with electrodes on the outer surface. The balloon is inflated so the electrodes are touching the abnormal tissue in the lining of the esophagus. The electrodes deliver enough energy to destroy thin layers of the diseased or abnormal tissue.

Barrett’s Esophagus is a condition in which tissue that is similar to the lining of our intestine replaces the tissue lining in your esophagus. The procedure is usually done as an outpatient and during an upper endoscopy. It takes approximately 45 minutes to complete the procedure. If you are scheduled for an RFA, your physician will discuss the preparation, the procedure risks and expected outcome.

PEG Tube

PEG stands for Percutaneous endoscopic gastrostomy and is a procedure through which a flexible feeding tube is placed though the abdominal wall and into the stomach. It allows nutrition, fluids and medications to be put into the stomach, bypassing the mouth and the esophagus.

How is the PEG Tube performed?

The doctor uses a lighted flexible tube called and endoscope to guide the creation of a small opening through the skin of the abdomen and directly into the stomach. This procedure allows the doctor to place and secure a feeding tube into the stomach. Patients generally receive a mild sedative and local anesthesia. Patients can usually go home the same day or the next day.

Patients who have difficulty swallowing, problems with their appetite or inability to take enough nutrition though the mouth can benefit from this procedure. Your provider will review care the peg tube, feeding and potential complications along with complete instructions.

Hemorrhoid Banding

This highly effective, minimally invasive procedure is performed in our offices.

During the brief and painless procedure, our physicians place a tiny rubber band around the base of the hemorrhoid.

The procedure works by cutting off the blood supply to the hemorrhoid. This causes the hemorrhoid to shrink and fall off, typically within a day or so.

You probably won’t even notice when this happens or be able to spot the rubber band in the toilet. Once the hemorrhoid is gone, the wound usually heals within one to five days.

Procedure Information:

• Fast: This is a fast in office procedure which takes approximately one minute to perform.
• Painless: Banding is typically without much pain since it is an area without nerve endings.
• No Sedation: You will be able to drive yourself to and from the appointment since there is no sedation. You will also be able to return to work.
• No Bowel Prep: There is no fasting, no cleansing and no enemas needed for this procedure
• No Downtime: You can get right back to your daily activities and lifestyle. (You are asked to refrain from strenuous activity until the following day.)

The physicians at EPGI use a smaller, gentler disposable suction device to minimize discomfort and lesson the complication risk. During the first 24 hours, some patients may experience a feeling of fullness or a dull ache in the rectum. This can typically be relieved with an over-the-counter pain medication. However, more than 90% of patients treated with this method have no post-procedure pain.

Flexible sigmoidoscopy

Flexible sigmoidoscopy is the endoscopic examination of the rectum and sigmoid colon. This is not an examination of the entire colon. Flexible sigmoidoscopy enables the physician to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid or descending colon. Physicians may use the procedure to find the cause of diarrhea, abdominal pain, or constipation. They also use it to look for early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. Flexible sigmoidoscopy is not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon).

For the procedure, you will lie on your left side on the examining table. The physician will insert a short, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a sigmoidoscope (sig-MOY-duh-skope). The scope transmits an image of the inside of the rectum and colon, so the physician can carefully examine the lining of these organs. The scope also blows air into these organs, which inflates them and helps the physician see better.

If anything unusual is in your rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing.

Bleeding and puncture of the colon are possible complications of sigmoidoscopy. However, such complications are uncommon.

Flexible sigmoidoscopy takes 10 to 20 minutes. During the procedure, you might feel pressure and slight cramping in your lower abdomen. You will feel better afterward when the air leaves your colon. There is no sedation required, so you should be able to drive to and from your office visit the day of your procedure.

Preparation

The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe. The night before the procedure, administer the FIRST Fleets enema at least one hour before bedtime. Administer the SECOND Fleets enema at least one hour before leaving for your procedure.

Your EPGI physician may give you other special instructions.

Esophageal Manometry Test

If you have symptoms such as difficulty swallowing or chest pain, your doctor might order an esophageal manometry. This test measures the function of the lower esophageal sphincter (the valve that prevents reflux of gastric acid into the esophagus), indicating if you are able to move food to the stomach normally.

What is esophageal manometry?

Esophageal manometry is a test used to measure the function of the lower esophageal sphincter (the valve that prevents reflux of gastric acid into the esophagus) and the muscles of the esophagus (see diagram). This test will tell your doctor if your esophagus is able to move food to your stomach normally. To know why you might be experiencing a problem with your digestive system, it helps to understand the swallowing and digestive processes.

The manometry test is commonly given to people who have:

Difficulty swallowing
Pain when swallowing
Heartburn
Chest pain

The swallowing and digestive processes

When you swallow, food moves down your esophagus and into your stomach with the assistance of a wave-like motion called peristalsis. Disruptions in this wave-like motion may cause chest pain or problems with swallowing.

In addition, the muscular valve connecting the esophagus with the stomach, called the esophageal sphincter, prevents food and acid from backing up out of the stomach into the esophagus. If this valve does not work properly, food and stomach acids can enter the esophagus and cause a condition called gastroesophageal reflux disease (GERD). Manometry will indicate not only how well the esophagus is able to move food down the esophagus but also how well the esophageal sphincter is working to prevent reflux.

Eating and drinking

Do not eat or drink after midnight the night before the test.

The Day of the test

You may take any antacids up until 12 midnight the night before the test.
DO not smoke or drink alcohol after 10 pm the evening before the test.
You will be instructed by your doctor regarding the medications you can take the morning of your procedure.

During the test

You are not sedated. However, a topical anesthetic (pain-relieving medication) will be applied to your nose to make the passage of the tube more comfortable.
A small, flexible tube is passed through your nose, down your esophagus and into your stomach. The tube does not interfere with your breathing. You will be seated while the tube is inserted.
You may feel some discomfort as the tube is being placed, but it takes only about a minute to place the tube. Most patients quickly adjust to the tube’s presence. Vomiting and coughing are possible when the tube is being placed, but are rare.
The end of the tube exiting your nose is connected to a machine that records the pressure exerted on the tube. Sensors at various locations on the tubing sense the strength of the lower esophageal sphincter and muscles of the esophagus. During the test, you will be asked to swallow a small amount of water to evaluate how well the sphincter and muscles are working. The sensors also measure the strength and coordination of the contractions in the esophagus as you swallow.
The test will take approximately 1 – 1.5 hours.

After the test

Your physician will notify you when the test results are available or will discuss the results with you at your next scheduled appointment.
You may resume your normal diet and activities and any medications that were withheld for this test.
You may feel a temporary soreness in your throat. Lozenges or gargling with salt water may help.
If you think you may be experiencing any unusual symptoms or side effects, call your doctor.

Endoscopic ultrasound (EUS)

Endoscopic ultrasound (EUS) allows your doctor to examine the lining of your upper and lower gastrointestinal tract. The upper tract consists of the esophagus, stomach and duodenum (the first part of the small intestine). The lower tract includes your colon (large intestine) and rectum. EUS is also used to study other organs near the gastrointestinal tract, including the lungs, liver, gallbladder and pancreas.

Our EPGI physicians who perform EUS are highly trained specialists. To perform EUS, your doctor will use a thin, flexible tube called an endoscope that has a built –in miniature ultrasound probe. The endoscope will be passed through your mouth or anus to the area to be examined and ultrasound images will be taken.

Double Balloon Enteroscopy

Double Balloon Enteroscopy, also known as a push and pull enteroscopy, is an endoscopic technique for visualization of the small bowel. The technique for advancement, using the double balloon enteroscopy method, uses a push pull method with inflammation and deflation of two balloons and telescoping of the intestines onto an over tube. Double Balloon enteroscopy can be done in an antegrade (through the mouth) and /or retrograde (through the rectum) approach.

Through this technique, it is possible to biopsy tissue, dilate strictures, remove polyps and stop bleeding from the small bowel. Balloon assisted enteroscopy can be performed in an outpatient or inpatient setting and may require several hours (depending on the therapy required). It is often performed with general anesthesia or moderate sedation.

Double Balloon enteroscopy (DBE) is not used as a first line therapy and is performed after careful evaluation by a specialty trained gastroenterologist. In the event your gastroenterologist orders this test, he or she will discuss the procedure, benefits, potential risks and outcomes.

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The Crohn’s and Colitis Center at EPGI

What We Treat:

Inflammatory bowel disease (IBD), a condition that causes inflammation (i.e. pain, swelling) of the gastrointestinal tract, comes in two main forms: Crohn’s disease and ulcerative colitis. It affects millions of people in the United States of all ages, although it most commonly develops in teenagers and young adults. IBD can cause abdominal pain, diarrhea, bloody stool, weight loss, vomiting, and fatigue. While it is a life-long condition, there are more treatment options available now than ever before in order to get patients into remission and give them the quality of life that they deserve.

Who We Are:

The Crohn’s and Colitis Center at EPGI offers world-class IBD care to the residents of the Lehigh Valley and the Poconos. Our board-certified gastroenterologists have special expertise in the management of IBD and employ modern and evidence-based techniques while maintaining a personalized and compassionate approach to care. We prescribe all approved therapies for IBD and use the most advanced and cutting-edge techniques to monitor our patients, including video capsule endoscopy, chromoendoscopy, double-balloon enteroscopy, endoscopic stricture dilation, and therapeutic drug monitoring. Our on-site infusion suite located in Allentown provides patients with a comfortable atmosphere and is managed by highly trained and personable staff.

Collaboration

The Crohn’s and Colitis Center at EPGI believes strongly in collaboration and teamwork. This is why we participate in regular videoconferences with IBD specialists located all across the United States to discuss our most challenging cases. Multidisciplinary meetings are also held locally with Lehigh Valley-based colorectal surgeons to help coordinate patient care. We also have dedicated personnel, Jen Scarpa and Nicole Held, who help navigate the logistics of IBD care and ensure patients are getting the care that they deserve.

COVID-19 and IBD

The COVD-19 pandemic presents unique challenges to patients with IBD. The Crohn’s and Colitis Center at EPGI have established robust protocols in alignment with national and international recommendations to ensure our patients are getting the best possible care during these trying times. To learn more about IBD and COVID-19, please visit: https://www.crohnscolitisfoundation.org/coronavirus/adults.

Contact Us

Whether you were recently diagnosed with IBD or are in need of a second opinion, we look forward to partnering with you. Please contact us at 610-821-2828 to schedule an appointment.

Patient Education

To learn more about IBD, please visit https://online.crohnscolitisfoundation.org.

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