Office Visit Forms
Please print, sign, and bring all forms with you to your office appointment.
- Patient’s Bill of Rights TGI – Tucson Gastroenterology Institute
- COVID Informed Consent to Treat TGI – Tucson Gastroenterology Institute
- HIPPA Form TGI – Tucson Gastroenterology Institute
- HIPPA Form TGS – Tucson Gastroenterology Specialists
- Health History Form TGS -Tucson Gastroenterology Specialists
- Insurance Authorization/Financial Responsibility -Tucson Gastroenterology Specialists
- Advanced Care Planning
- Miralax Bowel Prep Instructions (English)
- Miralax Bowel Prep Instructions (Spanish)
Please print, sign, and bring all forms with you on the day of your procedure.
Please contact a member of our medical staff at (520) 327-3454 to ensure that you have selected the appropriate bowel prep instructions for your procedure. Thank you!
Procedure Prep Instructions
Dr. McNerney’s & Dr. Hanna’s Prep Instructions
Dr. McCallum’s Prep Instructions
Our providers are contracted with numerous insurance plans to meet your medical needs. If you don’t see your plan listed below, please contact your insurance company to see if our providers are in your network. We always recommend that you speak with your insurance company to verify that our providers are in your network. If your insurance plan requires a referral to be seen by a specialist, please contact your primary care provider prior to your appointment date and ask them to fax your referral along with any pertinent medical records to (520) 327-3431. This will allow our providers to provide the necessary care during your appointment.
- AARP UHC Medicare Advantage
- AHCCCS-American Indian Health
- AHCCCS-Health Choice Generations
- AHCCCS-Mercy Care Advantage
- AHCCCS-Univ. Family Care & Medicare Advantage
- AZ Foundation For Medical Care
- BCBS Advantage
- Cigna Health Springs
- First Health
- Golden Rule
- Great West
- Health Net
- Humana Medicare Advantage
- Mail Handlers
- Medicare & Medicare Railroad
- Tricare for Life
- Tricare Prime
- Tricare Standard/Select
- United Health Care
- United Health Care-Medicare Complete
- UHC Community Plan
- UHC Community Dual Complete
- Veteran’s Choice Program
You may contact the billing office directly at (520) 382-1145 to discuss your statement, ask questions regarding physician or facility billing, or to make a payment over the phone.
In the event that you are scheduled for an endoscopic procedure, you should be aware of some important information regarding how your services will be billed to your insurance company. The total cost for your procedure may include up to three different billable services: The Physician’s fee, the Facility fee and the Pathologist’s fee (if biopsies are taken). Each fee will be billed separately to your insurance company by the performing provider.
The physician’s professional fee is for performing the Endoscopy procedure, supervising, interpreting, and consulting with you and your referring physician. Any bill for these services will be submitted under your physician’s name. For questions regarding the Physician fee billing, please contact our professional billing staff at (520) 382-1145 and they will gladly assist you.
The facility component of your service will be billed from Tucson Gastroenterology Institute or Tucson Medical Center if your procedure is done there. Facility fees cover the cost of providing the technicians, nurses, equipment, and supplies involved in the procedure. For any questions regarding the facility fee billing for Tucson Gastroenterology Institute, please contact our professional billing staff at (520) 382-1145 and they will gladly assist you.
If biopsies are taken during your procedure, you will be billed by the pathologist reviewing the tissue sample. If you have any questions regarding your pathology bill please contact the pathologist directly, using the information provided on their statement.
We will bill your services to your primary insurance company and a secondary insurance company if one is provided by you. Please familiarize yourself with your Outpatient Surgical benefits prior to your procedure. If your insurance plan mandates that you are financially responsible for payment of co-pays, deductibles, co-insurances, or non-covered services, we will be contractually obligated to collect them. Facility fees for Tucson Gastroenterology Institute are always due in full at the time of service. For proceures done at Tucson Medical Center please contact them directly for facility billing questions at (520) 327-5461.
As a courtesy and service to our patients, the billing office can assist you with understanding and estimating your financial responsibility prior to your procedure. Please call (520) 382-1145 to speak with a billing staff member. Estimates provided by billing staff are not a guarantee of payment in full by you. Any patient responsibility that is due after your insurance company has processed the claim(s), will be billed to you via a statement. Any patient balance is due in full upon receipt. Some patients may have riders, pre-existing conditions, preventive services, frequency limitations, or other services that may not be covered by their health plan. Please review your insurance benefits or contact member services prior to your appointment date.
The billing office is dedicated to making sure your financial concerns and questions are answered prior to and after your procedure. We look forward to serving you.