Patient Forms

Like any licensed healthcare service provider, we are required to obtain specific information regarding our patients and their unique circumstances to ensure the highest level of quality care and service. Please complete any of the applicable forms listed below as directed by our staff so we can help you get the most from your experience with us.

Policies & Guidelines

If you need to cancel, please call us at least two business days (48 hours) before your appointment. This helps us offer the time to another patient who needs to be seen.

If you cancel late or miss your appointment, you may be charged a fee. The fee is $25.00 for each office visit and $100.00 for each procedure.

Insurance does not cover these fees. You must pay them before you can schedule another appointment. You may be dismissed from the practice if you miss three appointments, procedures, or a combination of both within a 12‑month period.

Ohio Gastroenterology Group, Inc. takes confidentiality and security of all information seriously. Therefore, we restrict access to areas where patient information is maintained and access to private health information (PHI) is granted only to physicians and staff who need access to perform their duties. In addition, we have internal procedures that are designed to protect your PHI from unauthorized disclosures.

Click HERE to access the entire HIPAA Notice.

Thank you for choosing Ohio Gastroenterology Group and Central Ohio Endoscopy Center. We are committed to providing you the best possible medical care. We want to help you understand your costs, avoid surprises, and keep your costs to a minimum. This policy explains what to expect before, during, and after your visit.

Fees & Payments

Fees are standardized and based on how complex your visit or procedure is. You must pay your co-pay when you arrive for your appointment. You must also pay any unpaid balance at that time. We accept Personal Checks, Money Orders, Credit and Debit Cards (America Express, Visa, Mastercard, and Discover).

We will submit your insurance claim to your insurance company when we have your current insurance information on file. You are responsible for all costs not paid by your insurance. You must provide your most current insurance card at each visit and notify us right away of any insurance changes.

Insurance Plans

Your insurance coverage is a contract between you and your insurance company. We are not a part of that contract.

Before your visit, contact your insurance company. Ask them:

  • If the provider you are scheduled with is in-network
  • If the facility you are scheduled with is in network
  • If the services you plan to receive are covered

This helps avoid unexpected costs.

Procedure Charges

If you have a procedure at a hospital or one of our centers, you will get more than one bill and will see several types of charges. The bills and charges may include a:

  • Professional fee for the physician doing the procedure
  • Facility fee for the hospital or endoscopy center where the procedure is done
  • Lab fee if a biopsy is taken
  • Fee for anesthesia if you receive anesthesia

Missed Appointments & Cancellations

If you need to cancel, please call us at least two business days (48 hours) before your appointment. This helps us offer the time to another patient who needs to be seen.

If you cancel late or miss your appointment, you may be charged a fee. The fee is $25.00 for each office visit and $100.00 for each procedure.

Insurance does not cover these fees. You must pay them before you can schedule another appointment. You may be dismissed from the practice if you miss three appointments, procedures, or a combination of both within a 12‑month period.

Non-Payment of Outstanding Balances

Payment is due upon receipt of your first statement. If your balance remains unpaid after 60 days, your account will be considered past due. Past due accounts may be subject to additional collection efforts and reported to credit bureaus. Past due balances must be paid prior to scheduling non-urgent future appointments.

Disability Forms

Disability, FMLA, Life Insurance, and other forms must be reviewed by our clinicians. It may take 5–7 days for completion. There is a $45.00 fee for this service. You must pay this fee in advance.

Medical Records Fee

You can get a copy of your medical records by email or fax for free. If the records are mailed, there may be a fee.

If a doctor involved in your care requests your records, there is no charge (unless the doctor is moving to a new practice).

Other requests may be billed.

Return Check Fee

If a check is returned due to insufficient funds, there will be a $30.00 fee. You are still responsible for the original amount. Your bank may also charge a fee.

Self-Pay & Out of Network Insurance

You have the right to receive a Good Faith Estimate. This estimate explains what your care may cost. To request an estimate, call our billing department at 614-457-4220 or email billing@ohiogastro.com.

Click HERE to download PDF version.