Patient Forms

Established patients can use our AG Patient Portal to fill out their medical history forms online, pay bills or request appointments. To use this free, secure web service, you'll need to create an account and log in to our website.

Login to our AG Patient Portal to fill out your forms.

Are you a new patient? Is this your first time visiting an AG office? Please fill out each of the following forms prior to your first appointment. If you choose to fill out these forms at our office, please arrive 20 minutes before your appointment.

• Patient Information Sheet (This form must be completed once per year for every patient.)
• Methods of Communication
• Uses and Disclosures of PHI
• Austin Gastroenterology Financial Policy
• Initial Patient History and Intake Form (If you haven't visited AG in 3 or more years, you will need to complete this form again.)

The following forms are intended for patients who have already scheduled an endoscopy center procedure. You should have received a copy of the applicable forms after scheduling your appointment. Please choose a form below if you have lost or misplaced the original.

Acknowledgement Form

• Patient Acknowledgement

Prep Forms

These forms are often accessed by existing patients.

• Authorization for Release of PHI (Patient Health Information) Please fill out this form if you are requesting a copy of your health records from AG.
• Notice of Privacy Practices This informational document is referenced in the General Consent form.
• Noticia de Practicas Privadas El Formulario de Consentimiento General hace referencia a este documento informativo.
• Uses and Disclosures of PHI Use this form to update your permission for healthcare information disclosure.

English
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-696-6775 (TTY: 1-800-735-2989).

Spanish
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-696-6775 (TTY: 1-800-735-2989).

Vietnamese
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-696-6775 (TTY: 1-800-735-2989).

Chinese
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-696-6775（TTY：1-800-735-2989).

Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-696-6775 (TTY: 1-800-735-2989) 번으로 전화해 주십시오.

Arabic
‎1-1-877-696-6775 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم رقم (1-800-735-2989):والبكم الصم ھ

Urdu
‎‎‎خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال ک 6775-696-877-1.(TTY: 1-800-735-2989)

Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-696-6775 (TTY: 1-800-735-2989).

French
ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-696-6775 (ATS: 1-800-735-2389).

Hindi
ध्यान द: यद आप हदी बोलते ह तो आपके िलए मुफ्त म भाषा सहायता सेवाएं उपलब्ध ह।1-877-696-6775 (TTY: 1-800-735-2989) पर कॉल कर।

Farsi
توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما .بگیرید تماس 6775-696-877-1-1
(TTY: 1-800-735-2389) با. باشد می فراھم

German
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-696-6775 (TTY: 1-800-735-2989).

Gujarati
ચુ ના: જો તમેજરાતી બોલતા હો, તો િન:લ્કુ ભાષા સહાય સેવાઓ તમારા માટઉપલબ્ધ છ. ફોન કરો 1-877-696-6775 (TTY: 1-800-735-2989).

Russian
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-696-6775 (телетайп: 1-800-735-2989).

Japanese
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-877-696-6775（TTY: 1-800-735-2989）まで、お電話にてご連絡ください。

Lao
ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-877-696-6775 (TTY: 1-800-735-2989).

Language Line
1-800-874-3972
Account # 688096

Discrimination is Against the Law

This Practice complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Practice does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Austin Gastroenterology:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, contact our office or mention when you schedule an appointment.

If you believe that this Practice has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our office in person or by postal mail, or by phone:

Austin Gastroenterology Central Business Office
9211 Waterford Centre Court.
Suite 200
Austin, TX 78758
512-420-0186

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.