Our Office Address:
1706 E Lamar Alexander Pkwy
Patient Forms
New and Returning Patient Forms
Informational Forms
Cover letter welcoming you to Blount Gastroenterology Associates and outlining what you must bring to your first appointment.
Patient History Form (Required)
This 2 page form will help you to share your medical history with your physician. Please complete this to the best of your ability and bring it with you to your appointment.
Medication Chart (recommended)
Please list your medications including how much you take and how often you take it as well as the name of the prescribing physician. If you are uncertain as to where to find the information you may bring in your medications and someone in the office can assist you in completing this form.
Patient Registration Form (Required)
This 1 page form must be brought with you or completed before being seen. This is where you share your contact information, your insurance information and who to contact in an emergency.
Patient Information
Billing Information
Billing for Procedures
(Informational)
This page explains why you will receive at least two statements if you have a procedure done. Short version: one is for the people (our doctors and staff) and one is for the equipment and facilities. You may also receive a separate bill from the anesthesiology and from pathology (if something is sent to a lab for testing). These statements should be sent out to you after your insurance has made their payments.
Billing Agreement (required)
This form explains when copays are due, how billing is done and gives Blount Gastroenterology Associates permission to bill the insurance company. This is also the same form that allows us to release information to your doctor or family members and to leave messages on your answering machine if you wish. Finally, this form confirms you have been given a copy of the Notice of Privacy Practices.
This must be updated once a year or when you have a change in Release of Information to whom you allow the practice to speak on your behalf.
Forms for Procedures
Advance Directives Form (Required)
Prior to any procedures in the Endoscopy Center, we are required by law to have you complete this form.
Billing for Procedures (Informational)
This page explains why you will receive at least two statements if you have a procedure done. Short version: one is for the people (our doctors and staff) and one is for the equipment and facilities. This is the same form that is under billing.
Notice of Privacy
Notice of Privacy Practices
This form outlines the privacy policy as required by law.
Notice of Privacy Practices (Spanish)
(Aviso de Practicas de Privacidad)
Esta forma describe la práctica de privacidad como exige la ley.