Schedule Colonoscopy

Successful submission of this form will result in scheduling of a procedure for the patient.
Service
Services Requested*
Patient Information
First Name*
Last Name*
Date of birth*
MM
DD
YYYY
Gender
- Male
- Female
Address*
Street Address Address Line 2 City State Zip Code
Phone
Email*

Please ensure email address is accurate. Patient will receive appointment confirmations at this address
Location
Scheduling location*
- As per patient preference
- I would like to define the center
Scheduling Location*
Billing Information
Member ID
Please enter an applicable identifier for your member.
Billing Responsibility*
- Patient is responsible for cost
- Our account will cover 100% of the cost
- Define patient copay as percentage (%)
- Define patient copay as dollar amount ($)
Patient copay percentage (%)?*
Patient copay amount ($)?*
By clicking "Submit" you are requesting ColonoscopyAssist to schedule the patient for the services requested. You are also providing a binding authorization and that your organization will cover the cost of services as per the terms entered under the billing responsibility section. No further authorizations will be requested.

Instructions

Successful submission of this form will result in scheduling of a colonoscopy for the patient.
You can look up locations available at colonoscopyassist.com

PROCESS

After submission of the form, patient will be contacted by a patient navigator to :

1) Determine date and time preferences for an appointment
2) Obtain a medical history
3) Coordinate any referrals necessary
3) Disseminate prep instructions

It is advisable to make patient aware that a patient navigator will be reaching out to them to coordinate the scheduling of the procedure.
Alternatively, you may advise the patient to call 855-542-6566 immediately after submission of this form to expedite scheduling.

Schedule Colonoscopy

Schedule Colonoscopy

Service

Patient Information

Location

Billing Information

Instructions