Digestive Health Associates

Southwest Endoscopy Center

Forms Online


Standard Form Packets


Please download, print and complete the form packets for your visit as directed by our office staff. 

These packets contain information for you about your scheduled visit or procedure and forms you should use to provide us with information we need about you.  As a Medicare-certified Ambulatory Surgical Center federal regulations require us to provide you with notices and disclosures in advance of the date of your procedure.  Our forms for private patients and Medicare patients are different because of Medicare requirements.  Patients who are not covered by insurance should download the "private insurance" version. 

These form packets pertain to patients undergoing procedures with the form of sedation we provide in most cases, in which a nurse anesthetist administers monitored anesthesia care in the form of "Endoscopist-supervised propofol sedation" as described in detail on our
Sedation Options page.  Patients who choose not to be sedated in this manner may arrange, with their endoscopist's consent, for moderate sedation services or endoscopy without sedation.  Moderate sedation has limitations which are important to understand prior to scheduling your procedure.  Special consent forms for moderate sedation are linked below. 


New Clinic Patient

This packet is for new patients scheduled to be seen in our clinic.


Open Access Upper Gastrointestinal Endoscopy (EGD)



These packets are for patients scheduled to undergo upper endoscopy who have been interviewed by one of our registered nurses.  In most cases all of the information and forms you will need are included.

 
 
Remember not to eat or drink absolutely anything for 2 hours prior to your procedure.
 

We encourage you to read our Upper Endoscopy FAQs and Sedation/Anesthesia FAQs.
Watch a video describing upper endoscopy.
Read "
Preparing for an Upper GI Endoscopy" from the American Gastroenterological Association.


Open Access Colonoscopy
Colonoscopy (for private insurance)  |  Colonoscopy (for Medicare)

These packets are for patients scheduled to undergo colonoscopy who have been interviewed by one of our registered nurses.  In most cases all of the information and forms you will need are included.  Please discard any "prep instructions" provided by you pharmacy or another health care provider and follow the instructions in this packet.


Remember not to eat or drink absolutely anything for 2 hours prior to your procedure.

 

In some cases our staff may direct you to use an alternate method of cleansing your colon.  You may download the alternate preparation instructions as directed below, and use them in place of the instructions included in the standard packet above.  All other pages of the standard packet will apply.


We encourage you to read
Colonoscopy FAQs
and Sedation/Anesthesia FAQs.
Watch a video describing colonoscopy.
Read "
Preparing for a Colonoscopy" from the American Gastroenterological Association.


Open Access Bidirectional Endoscopy (EGD-colonoscopy)
EGD-colon (private insurance)  |  EGD-colon (Medicare)

These packets are for patients scheduled to undergo EGD and colonoscopy under the same sedation/anesthetic who have been interviewed by one of our registered nurses.  In most cases all of the information and forms you will need are included.  Please discard any "prep instructions" provided by you pharmacy or another health care provider and follow the instructions in this packet.

In some cases our staff may direct you to use an alternate method of cleansing your colon.  You may download the alternate preparation instructions as directed below, and use them in place of the instructions included in the standard packet above.  All other pages of the standard packet will apply.

 

We encourage you to read Upper Endoscopy FAQs, Colonoscopy FAQsand Sedation/Anesthesia FAQs.
Watch videos describing
upper endoscopy and colonoscopy.

 




Special Forms
The instructions and forms in this section are for use only in specific situations.  Do not download the instructions or forms below unless you are specifically instructed to do so by our staff.  In most cases all necessary instructions are contained in the standard packets linked above.


Colonoscopy Prep Instructions


Esophageal Manometry (high resolution manometry with impedance testing)
Esophageal Manometry Preparation


Standard Procedure Consent Forms
These forms are provided for those instances in which an entire packet is not needed.
Upper Endoscopy (EGD) | Colonoscopy | Capsule endoscopy  |  Bravo pH Monitoring


Procedure Consent Forms for Moderate Sedation Only
Upper Endoscopy with Moderate Sedation  |  Colonoscopy with Moderate Sedation
Based on our experience providing more than 35,000 endoscopic procedures under various forms of sedation at the Southwest Endoscopy Center, we usually recommend that patients undergoing upper endoscopy or colonoscopy at our facility do so under "endoscopist-supervised propofol sedation," which we believe is superior to "moderate sedation" with respect to safety, comfort, tolerability and effectiveness.  Some insurance companies may however not cover anesthesia services, which are necessary to provide propofol sedation under current U.S. government rules, as specified by the Centers for Medicare and Medicaid Services, which regulates ambulatory surgery centers, hospitals and other facilities that are certified under the Medicare program.   Insurers who do not cover anesthesia services for colonoscopy often limit coverage to "moderate sedation."  Individuals choosing to schedule procedures without sedation or with moderate sedation must be familiar with the risks and benefits of doing so, as discussed on our
Sedation Options page.  We would be happy to schedule a preprocedure clinic visit to discuss your sedation options in detail.


Medication Treatment Consent Forms 

Steroid treatment  |  Immunosuppressive treatment  |  TNF-inhibitor treatment  |  PPI treatment


Advanced Beneficiary Notices (ABNs)
The sample ABN notices included in the Open Access form packets above are provided for informational purposes only.  Executable copies are available below. 

Anesthesia (for private insurance)  |  Anesthesia (for Medicare)  |  Anesthesia ABNs FAQs


Medical Records Forms

Authorization for Release of Information
Medical records contain federally protected health information.  This form must only be executed by appropriately authorized individuals.  Family members are not permitted access to an individual's protected health information on the basis of their relationship alone, and a family member "signing" on behalf of another, without legal authority to do so, may constitute forgery and fraud.  You may read more about the U.S. government's HIPAA Privacy Rule and Digestive Health's Privacy Notice through these links.



Colorado Regional Health Information Organization Forms
CORHIO is a nonprofit organization dedicated to improving health care in Colorado through health information exchange.

CORHIO helps doctors, hospitals and other health care providers connect our computer-based patient record systems to a protected statewide network. The network is used to securely share information for patient care and this is called health information exchange. Being connected to a health information exchange network allows health care professionals to access up-to-date patient information, which helps them provide you with better quality care. Additionally, the information is shared in a more protected way than paper-based files, faxes and mail.

Opt-Out Request Form  |  Opt-In Request Form


 

 

 
Advanced Directives


The laws regarding advanced directives, and the forms acceptable, vary from state to state.  Many states will recognize an advanced directive prepared in another state, where the patient resides, though this is not always true.  Some authorities recommend that patients receiving care outside their state of residence consider also preparing documents for the state within which the healthcare facility they are using resides.

Colorado
New!
  Legislation implementing the "
Medical Orders for Scope of Treatment" (MOST) program passed in 2010 and the MOST process is now being implemented.  Please follow the link for information about this program, including a downloadable instruction booklet and MOST form.

The following advance directive document is in the process of being replaced by the MOST program, which is now in an implementation.  Many medical providers in Colorado are not yet familiar with MOST.
Your Right To Make Health Care Decisions.  This document reviews your rights to make health care decisions under Colorado law, including the right to accept or refuse medical treatment.  It explains and provides the forms necessary to document your decisions with regard to the following advance directives and related subjects:
-Medical Durable Power of Attorney
-Living Wills
-Cardiopulmonary Resuscitation (CPR Directive)
-Substitute Decision Makers (Medical Proxies)
-Guardians

Other States
Advance directive information and forms for residents of other states: 
New Mexico | Utah | Arizona
General advance directive information
, with forms for other states



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Southwest Endoscopy Center
Western Colorado's Accredited Endoscopy Center