Donald Hazzard #216418

Donald Hazzard 1421 Melvin St Ypsilanti, MI 48198

Appointment Scheduled: Appointment Date: Arrival Time: Provider:

Colonoscopy

10/07/2010

8:45 AM

Stanley R Strasius, MD

Location: Center for Digestive Care

Please note your appointment information below.

Please note your appointment time is scheduled for 9:30 AM. It is extremely important you arrive at the arrival time of 8:45 AM. If you have any questions regarding your appointment please call our office and ask for the scheduling department at (734) 434-6262 or (800) 772-4659. Or, if it is more convenient, please go online to www.hurongastro.com, click on patient login and follow the step by step instructions to set up an account and request an appointment. This option is available to you 24 hours a day, 7 days a week. We also encourage you to use the other options available to you on the site. If you need to cancel or reschedule please call us as soon as possible. There is a late cancellation fee of $25.00 for office patients and $50.00 for procedure patients, if cancelled with less than 24 hours notice.

Thank you

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Donald Hazzard #216418

Huron Gastroenterology Associates Ypsilanti, MI 48197 734.434.6262 or 800.772.4659 Welcome to Huron Gastro (HG). Enclosed are several informational items that will acquaint you with the practice and provide information about your upcoming appointment. We encourage you to take a few moments to look through the packet. If you have any questions or concerns, please feel free to call a member of our staff. We also have a Web Site designed to assist patients with frequently asked questions and directions. Visit us at www.hurongastro.com

Please follow the instructions below.

1. Read the enclosed procedure preparation well in advance of your appointment. 2. If you received a patient information sheet and health history questionnaire, complete the forms and bring those with you to your appointment. If you prefer to complete the forms on line rather than the paper version, go to www.hurongastro.com. If you choose to complete the forms electronically, please do so as soon as possible. If you have already completed these forms online, please disregard this part of the mailing. 3. Bring all insurance cards and a hospital outpatient card (if you have one) with you to your appointment. 4. List all medications you are currently taking on the enclosed form and bring that with you to your appointment. 5. You must arrive with a responsible driver 18 years of age or older at your scheduled appointment time. Your driver must remain in the waiting room during your procedure. The hospital policy is that patients who do not have a driver will be rescheduled or their procedure will be performed without sedation. 6. A member of our clinical staff may contact you to obtain additional information to ensure that your procedure meets the medical and payment criteria of your insurance plan. 7. Bring your drivers license or a photo ID to your appointment.

Directions:
Center for Digestive Care (CDC at St. Joseph Hospital) 5300 Elliott Drive, Ypsilanti, MI 48197 Lot U for the West Entrance Lot M for the East Entrance From 1-94: Take Michigan Avenue exit 181. Head east toward Ypsilanti. Turn left onto Hewitt. Continue north (est. 2.5 miles), cross Huron River Drive and enter the main campus of St. Joseph Mercy Hospital. From 1-96 or M-14: Take US 23 South to exit 39, Geddes Road. Turn left (East) onto Geddes Road. From Geddes Road take a right onto Dixboro Road. Follow Dixboro until it runs into a three-way stop-light (the overhead sign will say Huron River Drive). Continue through that stop-light, curving to the left until you reach St. Joseph Mercy Hospital campus (on your left). Follow the signage for SPECIALITY CENTERS (Michigan Heart, Michigan Orthopedic, Women's Health, Center for Digestive Care).

Reminder
If you need to cancel or reschedule please call us as soon as possible. There is a late cancellation fee of $25.00 for office patients and $50.00 for procedure patients if not cancelled within 24 hours of the appointment. We also offer the ability to request an appointment via the internet, please visit our website at www.hurongastro.com . Click on Patient Login and follow the step-by-step instructions to set up an account and request an appointment. The option is available to you 24 hours a day, 7 days a week. We also encourage you to use the other options to you on the site.

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Donald Hazzard #216418

If you prefer to complete this form on line rather than the paper version, go to www.hurongastro.com.

PATIENT HISTORY QUESTIONNAIRE

To Be Completed By Patient Prior to First Appointment DATE OF BIRTH___________________________ TODAYS DATE________________________

PRIMARY PHYSICIAN_______________________________________________________________ Describe the symptoms, and length of time of symptoms that led to your appointment: _____________ ___________________________________________________________________________________

DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS: Constitutional:

Weight Gain Night sweats/hotflashes Weight loss Fever Fatigue

Yes

No

Gastrointestinal
Nausea and or vomiting Diarrhea Constipation Hemorrhoids Heartburn and/or Indigestion Difficulty swallowing Increased belching or burping Loss of appetite Abdominal Pain Passing excessive gas Vomited any blood Blood in your stool Leaking stool or accidents Mucus in your stool Jaundice (skin or whites of eyes) Any acid reflux (stomach acid taste) or regurgitation

Yes

No

HEENT:
Frequent Headaches Double/blurred vision Hearing Loss

Yes

No

Respiratory
Difficulty breathing/ shortness of breath New cough

Yes

No

Cardiovascular
Chest pain or pressure Heart palpitations/fluttering

Yes

No Genitourinary:
Frequent or painful urination Blood in urine

Yes

No

Vascular:
Leg cramps with walking (Claudication) Change of color in hands or feet (Raynaud's)

Yes

No

Neuro/Psychiatric
Fainting or dizzy spells Emotional Problems Convulsions or seizures Numbness/tingling

Yes

No

Dermatologic:
Itching Any rashes, sores, color changes or spots on skin

Yes

No

Musculoskeletal:
Joint Pain Back Pain

Yes

No

Reproductive: Hematology:
Easy bruising or bleeding Frequent nose bleeds

Yes

No

Yes

No

Sexual Difficulties Menstrual Difficulty If yes describe_________________________ Date of last period___________________________

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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MAJOR MEDICAL ILLNESSES Yes No

Heart Disease Heart Stent Artificial Heart Valve Heart By-Pass Atrial Fibrillation Diabetes Seizures Asthma Emphysema/COPD Hepatitis

Yes

No

Hypertension/ High Blood Pressure Arthritis HIV/AIDS Glaucoma Sleep Apnea Tuberculosis Cancer If yes, what type: ___________________ Other:____________________________

LIST ANY HOSPITALIZATIONS AND SURGERIES

REASON YEAR HOSPITAL PHYSICIAN

HAVE YOU HAD ANY OF THE FOLLOWING DONE?

YES Hidden blood in stool test Upper GI X-ray Lower GI X-ray (Barium Enema) CT Scan Sigmoidoscopy Colonoscopy Gastroscopy FAMILY HISTORY FATHER MOTHER BROTHERS SISTERS CHILDREN (Circle which) Family history of: Colon Cancer or Polyps YES (Who) NO Family history of other cancers? YES (Who) NO ALIVE DECEASED IMPORTANT MEDICAL PROBLEMS NO DATE

Family history of: Crohn's or Ulcerative Colitis

Family history of liver disease?

A. WORK ENVIRONMENT Occupation______________________________ Stress Level (Low) 1 2 3 4 5 (High)

B. TRAVEL (within the last year) _____ Out of Michigan _____ Out of U.S.?

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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DO YOU DRINK THE FOLLOWING?

COFFEE MILK / DAIRY PRODUCTS TEA COLA / POP / CHOCOLATE

AMOUNT PER DAY

Please answer the following: Do you smoke? Packs per day __________

YES

NO

Are you an ex-smoker? When did you quit? __________ Do you chew tobacco? Do you drink alcohol? Drinks per day ______ or Drinks per week ______

Have you ever abused drugs? _____ Prescriptions _____ Illicit _____ Over the counter MEDICATIONS: PRESCRIPTION (Bring medicines to the office with you) NAME DOSAGE HOW OFTEN?

MEDICATIONS: NON-PRESCRIPTION (Please include aspirin, Advil, Nuprin, Tylenol, etc.) NAME DOSAGE HOW OFTEN?

ANY ALLERGIES OR SIDE EFFECTS TO Medication Reaction

HAVE YOU EVER HAD A REACTION TO ANESTHESIA? Nausea / Vomiting? Difficulty Waking Up Fever? Heart Problems? Other?

Have any of your family members ever had a reaction to anesthesia? ____ Yes ____ No What questions would you like answered at your visit?
1. 2. 3.

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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The intent of this document is to inform our patients about the financial policies of Huron Gastroenterology (HG) and Center for Digestive Care (CDC) in order to reduce confusion and misunderstanding. If you have questions about the policy, please ask to speak with a member of our Patient Financial Services team. We are dedicated to providing the best possible care and service to you and regard your complete understanding of our financial responsibilities as an essential element of your care and treatment. Payment for services is due in full at the time services are rendered. However, if you have health insurance that either HG or CDC has a participation agreement with, such as Medicare, Blue Cross, Priority Health, or others, we will submit a claim to your primary and secondary insurance. You will be required to pay the authorized copayment at the time of service.

At the time you make your appointment, please check if HG/CDC has a participating arrangement with your insurance company. Whenever you are having a procedure/surgery performed in a hospital facility, it is important to check if the facility also participates with your insurance company. It is the patient's responsibility to make this determination.

PRACTICE FINANCIAL POLICY

(734) 434-6262 (800) 772-4659

If you are a member of a health care organization that HG/CDC does not have a participation agreement with, we will prepare and submit a claim for you. This means your insurer will send the payment directly to you. The charges for your care and treatment are due at the time of service for HG patients and when billed for CDC patients. There is a $25.00 no show or late cancellation charge for office patients and $50.00 for procedure patients. In order to avoid such charges, it is important that you call a member of our scheduling department to cancel your appointment a minimum of 24 hours prior to your appointment. This courtesy allows other patients who are waiting for an appointment to use this time slot. Medicare patients are responsible for their co-payments and any items deemed Medically Unnecessary by Medicare. In the event your health plan determines services to be not covered you will be responsible for the complete charge. You will be asked to sign a waiver prior to receiving the services indicating that they may not be covered by your insurance plan. In the event your insurance plan determines the services you received are "a non-covered benefit" and/or you have not obtained any necessary pre-authorization you will be responsible for the complete charge. You will be asked to sign a waiver prior to receiving the services indicating that they may not be covered by your insurance plan. If you are unable to pay for the visit at the time of service, please call our office prior to the appointment to arrange a payment plan. Patients will receive a monthly statement itemizing the services rendered, payment received, and any unpaid patient balance. For all services rendered to minor patients, we will look to the adult accompanying the patient and the parent or guardian with custody for payment. We will bill your health plan for all services provided in the hospital. Any balance due is your responsibility and is due upon receipt of a monthly statement. HG/CDC accepts cash, personal checks, money orders, travelers checks, MasterCard, Visa and Discover. A $25 fee will be assessed to the account for every check returned to HG/CDC for insufficient funds. HG/CDC reserves the right to turn any patient over to collections if it is deemed that the account has been in default of the payment obligations or compliance of this policy.

I have read and understand the above Financial Policy. I also understand and agree that such terms may be amended from time-to-time by the practice.

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Donald Hazzard #216418

Split Dose Gatorade/Miralax Prep

We at Huron Gastro are happy that you and your physician have made the choice to trust us with your digestive healthcare. By scheduling a colonoscopy, you have taken the first step to preserving your health for years to come. If you have cirrhosis, congestive heart failure or kidney failure you should not take this prep and instead use the Golytely prep (see website or contact us since a prescription is required). We want your procedure to go as smoothly as possible. In order for that to happen, there are some tips we have included in this bowel prep sheet. Now, heres what to do to get ready:

3 Days Before Your Procedure

* * *

Obtain Miralax from your pharmacy. It comes in a 8.3 oz (238 gm) bottle. No prescription is needed. Obtain Dulcolax laxative (not stool softener) from your pharmacy. You need a total of 4 Dulcolax laxative tablets. It is okay to substitute a less expensive generic for brand name Dulcolax. No prescription is needed. Obtain a total of 64 ounces of Gatorade. You can either buy one 64 ounce bottle or two 32 ounce bottles. Avoid red colors. These can make it harder for the doctor to perform an accurate exam. If you have diabetes you can try "G2" (low calorie Gatorade) or "Powerade Option/Zero" as another choice.

2 Days Before Your Procedure

Avoid nuts, seeds, and salads. These can make it harder for your doctor to perform an accurate exam.

1 Day Before Your Procedure

Follow a clear liquid diet beginning after breakfast (approx 10am). A clear liquid diet includes water, coffee (only if you must- limit to 8 oz), tea, soda, broth or clear juice like apple juice or white grape juice, popsicles, and Jell-O (no added fruit). Avoid red colors. No milk products. Do not eat any solid food. Swallow 2 of the Dulcolax tablets at about 1pm. At about 5:00 p.m. mix your Gatorade and the entire container of Miralax and begin drinking. Once you mix the Miralax powder into the Gatorade, make sure you shake it up so it is fully dissolved.

* *

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Start by drinking 8 ounces of the mix every 15 minutes but save the last 2 glasses (about 16 ounces) for tomorrow morning. If you start to feel nauseated you can drink the mix more slowly. Some patients tell us that walking around relieves nausea. Most people will begin to have diarrhea usually within 2 hours after drinking the mix. Eventually, the diarrhea should be thin liquid with no pieces. Although this is unpleasant, it allows the doctor to perform an accurate exam.

* * * *

Swallow the other 2 Dulcolax tablets at about 8pm (even if you haven't completed the Gatorade).

Day of Your Procedure

Drink the last 2 glasses (about 16 ounces) of the mix 4-6 hours prior to your scheduled procedure. If you have an early morning procedure, this may require you to awaken very early! Continue to drink clear liquids until 3 hours before your procedure. Do not eat any solid food.

Overview: 3 days before

- Buy Miralax - Buy Dulcolax - Buy Gatorade

2 days before
- No nuts, seeds, salads

1 day before
- Begin a clear liquid diet after breakfast (approx 10am) - Take 2 Dulcolax tablets at 1pm - Mix entire container of Miralax and Gatorade at 5pm - Drink 8 ounces of mix every 15 min but save the last 2 glasses (16 ounces) for tomorrow morning - Take 2 Dulcolax tablets at 8pm

Day of Procedure
- No solid food - 4-6 hours prior to your procedure time, drink the last 2 glasses (about 16 ounces) of mix - Continue to drink clear liquids until 3 hours before procedure - Do not eat any solid food

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Donald Hazzard #216418

DAY OF EXAMINATION

You may drink clear liquids until 3 hours prior to the exam. Sips are allowed thereafter if medications need to be taken up until the time of the procedure.
MEDICATIONS

If you take insulin please make sure you are scheduled for an early morning appointment. Bring your insulin with you so that you can take it after the procedure has been completed and you are ready to eat. If you are taking anti-coagulant (blood thinning) medications such as Coumadin or Plavix, tell us immediately at the time of scheduling because your dosage may need adjustment prior to the procedure. Iron supplements need to be stopped 5 days prior to colonoscopy. All other medications should ordinarily be continued at their regular time and may be taken with a small amount of water. Please tell us if you are allergic to any pain medications or sedatives. Do not discontinue any medications unless you have discussed this with your physician.
ANTIBIOTICS BEFORE THE COLONOSCOPY

If you have an artificial heart valve or a history of endocarditis, you may (rarely) require antibiotics. Please inform us at the time your procedure is being scheduled. Unlike for dental procedures, prosthetic joints do not require antibiotics.
CONSENT

You will be asked to sign a consent form to authorize us to perform a colonoscopy with possible biopsy and removal of polyps. Some possible, but unlikely, risks of a colonoscopy include bleeding, perforation, infection and adverse reactions to the sedatives. The consent form and your physician will provide you with more details at the time of the procedure and give you the opportunity to ask questions.
PROCEDURE

We first ask you to turn onto your left side with your knees drawn up and then you will be given sedation intravenously. The medication takes effect quickly promoting relaxation, drowsiness and forgetfulness. You may fall asleep and later remember little if anything of the procedure. Then a lubricant is pressed into the rectum before the colonoscope is inserted. You may feel bloating when air is added to improve visibility and cramping when the colonoscope is rounding a turn.
AFTERWARDS

You should experience little if any discomfort. You may have a full feeling that will be relieved by passing gas. You will remain in our recovery room until the main effect of the intravenous medication has worn off. We will tell you about the results of your examination. Because you may not remember what we say, we recommend that your driver be present during this conversation. Please let us know at the time you check-in for your procedure if you prefer that your results not be discussed with your driver. After you get home, you can resume your usual diet and light activities. You must not drive a car, make important decisions or operate machinery the rest of the day and you will need to have someone available to be with you during check in, recovery, and to drive you home and if necessary, stay with you if you are sleepy, etc (A taxi or bus is not an option). This person (must be at least 18 years old) must remain at the endoscopy center from check-in to discharge. Some degree of apprehension is normal, but most patients find colonoscopy much less unpleasant than they anticipated. Our endoscopy staff will try to make your examination as comfortable as possible. If you have questions, please call our office at (734) 434-6262 or (800) 772-4659.

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Donald Hazzard #216418

You are scheduled for a colonoscopy with Huron Gastroenterology (HG)/Center for Digestive Care (CDC). Colonoscopy is one screening method recommended by the American Cancer Society and other professional organizations. The physicians of HG agree that a colonoscopy is the most effective means of screening. At the present time, however, many insurance carriers do not consider it a covered benefit for patients with an average risk of colon cancer (service not medically necessary.) In the event an abnormality is seen or suspected during the procedure, a portion of tissue (biopsy) may be removed or small growths (polyps), if seen, may be removed. This will result in the procedure being considered diagnostic versus screening. We encourage you to verify your coverage. Please consult your primary care physician and insurance company regarding colon cancer screening. To assist you with determining your coverage when contacting your insurance company, we have included screening and diagnostic codes below. If you have Medicare as your primary insurance, you may receive an Advanced Beneficiary Notice (ABN) in a separate mailing. After speaking with your primary care physician and insurance company you choose not to proceed with your scheduled colonoscopy, please call our office as soon as possible to cancel your appointment at (734) 434-6262. Procedure Codes: Screening Colonoscopy Codes: G0105 High Risk Colonoscopy G0121 Routine Screening Colonoscopy Diagnostic Colonoscopy Code: 45378 Screening Diagnosis Codes: V76.51 Screening Colonoscopy V1272 Personal History of Polyps V160 Family History of Colon Cancer Diagnosis Code if Polyps are Found: 2113 Colon Polyp

Sincerely, Huron Gastro Patient Financial Services

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Center for Digestive Care Notice of Physician Ownership Interest

You may have been referred to Center for Digestive Care by one of the providers listed below. The physicians listed below have an ownership interest in Center for Digestive Care, located at 5300 Elliott Drive, Ypsilanti, MI 48197. Please be advised that you have the right to obtain health care services for which you have been referred to Center for Digestive Care at the hospital or facility of your choice, including Center for Digestive Care.

Stanley Strasius, MD NPI: 1871573923 Manus Krasman, MD NPI: 1467431742 Russell Keinath, MD NPI: 1427037878 Larry Adler, MD NPI: 1356320634 Robert Stoler, MD NPI: 1952380081 Mary P. Mortell, MD NPI: 1851370142 John Walsh, MD NPI: 1982684643 Naresh Gunaratnam, MD NPI: 1194704486

Jeffrey Barnett, MD NPI: 1770562076 Thomas Shehab, MD NPI: 1114906559 Ali Yazdani, MD NPI: 157854333 Miriam Thomas, MD NPI: 1689654725 Andrew Catanzaro, MD NPI: 1326028481 Najm Soofi, MD NPI: 1902949761 Mark Zeglis, MD NPI: 1497898233 Stevany Peters, MD NPI: 1275689895

One of our mid-level providers may also have referred you to the Center for Digestive Care, but they do not have an ownership interest: Jill Smith, PA Deborah Viher, NP Fred Kominars, PA Mark Velarde, PA Erin Reed, PA

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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Donald Hazzard #216418

Center for Digestive Care Patient Notification Document

As an ambulatory surgery center (ASC) it is our responsibility to be sure patients have been informed of their rights. Below is information about your rights, how you can obtain additional information regarding advanced directives, and ownership interest of Center for Digestive Care (CDC).

Rights of Patients The following list of patient's rights is not intended to be all-inclusive.

* *

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 practitioners, the names of all other practitioners directly participating in his care, and the names and functions of other health care persons having direct contact with the patient. A Patient has the right to consideration of privacy concerning his own medical care program. Case discussion, consultation, examination, treatment, and medical records are considered confidential and shall be handled discreetly. A Patient has the right to confidential disclosures and records of his medical care except as otherwise provided by law or third party contractual arrangement. A Patient has the right to participate in decisions involving his health care except when such participation is contraindicated for medical reasons. A Patient has the right to know what Center for Digestive Care rules and regulations apply to his 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 layman's terms, concerning diagnosis, evaluation, 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 person designated by the patient or to a legally authorized person.

* * * * * *

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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* *

Except for emergencies, the practitioner shall obtain the necessary informed consent prior to the start of a procedure. If the patient is unable to give consent, a legally authorized person has the right to be advised when a practitioner is considering the patient as a part of a research program. The patient or responsible person shall give informed consent prior to participation in the program. The patient or responsible person may refuse to continue in a program to which he has previously given informed consent. A Patient has the right to refuse drugs or procedures. A practitioner shall inform the patient of the medical consequences of the patient's refusal of drugs or procedures. A Patient has the right to medical and nursing services without discrimination based upon age, race, color, religion, sex, national origin, handicap, disability, or source of payment. The Patient who does not speak English shall have access, where possible, to an interpreter. Hospital or office - get a list or at least contact person. Center for Digestive Care shall provide the patient, or patient designees, upon request, access to the information contained in his medical records, unless the attending practitioner for medical reasons specifically restricts access. The Patient has the right to expect good management techniques to be implemented within Center for Digestive Care. These techniques shall make effective use of time for the patient and minimize personal discomfort of the patient. When an emergency occurs and a patient is transferred to another facility, the responsible person shall be notified. The institution to which the patient is to be transferred shall be notified prior to the patient's transfer. The Patient has the right to examine and receive a detailed explanation of his bill. The Patient has the right to expect that Center for Digestive Care will provide information for continuing health care requirements following discharge. The Patient is informed of his/her right to change primary or specialty physician, if another qualified physician is available.

* * * *

* * *

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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The Patient has a right to receive information about Advance Directives prior to their scheduled appointment.

Should you wish to report a grievance:

* *

Please ask to speak with the manager of the surgery center or the administrator or call us at 734.528.1405. Contact the Michigan Department of Community Health Bureau of Health Systems, Compliant Investigation Unit P.O. Box 30664 Lansing, MI 48909 1-800-882-6006 Contact the Office of the Medicare beneficiary Ombudsman at www.cms.hhs.gov/center/ombudsman.asp 1-800-633-4227

Advance Directives An advance directive is a written document in which you specify what type of medical care you want in the future, or who you want to make decisions for you, should you lose the ability to make decisions for yourself. Having advance directives provides some assurance your personal wishes concerning medical and mental treatment will be honored at a time when you are not able to express them. Making these medical treatment decisions in advance will allow your family and friends to act on your behalf with confidence that they are following your wishes. When you come in for your procedure, we will ask you if you have advance directives. It will be documented in your medical record whether or not you have advance directives. Information concerning advanced directives is available at the Center for Digestive Care facility. To obtain a copy of this information call us at 734.434.6273.

for more information visit our website at www.HuronGastro.com or call (800) 772-4659
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