Dear Patient:
This letter is to explain our office policy. We are asking all patients to provide us with credit
card information as part of the patient registration process.
We are making this request to help facilitate the collections process of any balances that may
become your responsibility. Federal legislation and insurance companies desire to keep
premiums down has resulted in increasing copays, deductibles, and coinsurance requirements.
This in turn is significantly increasing the percentage of the healthcare bill that must be paid by
our patients.
This is very similar to many other industries that require credit card information prior to
accessing their services. It enables customers to set appointments, access services, and settle
accounts in an expeditious manner. This process has become commonplace in healthcare
facilities, including our community.
Please understand that while we are requesting this information, we have no intention of
charging your credit card without your knowledge. Nothing will be charged to you until we have
received payment or an explanation of benefits from your insurance company,
We hope you understand our need to implement policies that will enable us to more
effectively, and efficiently settle our balances with all of our patients. Please know that we are
always open to working with you should any issues, or problems arise.
Sincerely,
Dixie Schoonover
Executive Director
Illinois Gastroenterology, LLC
a member of Premier Medical Group, LLC
2200 Jacobssen Drive
Normal, IL. 61761
Notice of Privacy Practices and Patient Consent
For Use and Disclosure of Protected Health Information
_____________
MRN#
Patient Name: ________________________________________Date of Birth: __________________________________
(Please print)
Email: _______________________________________________Today's Date: __________________________________
I understand...

That under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding
my protected health information.
 That Illinois Gastroenterology, LLC /Mid-Central Illinois Gastroenterology , Ltd, a member of Premier Medical Group, LLC may use or disclose my protected health information for treatment, payment or health care operations - which means for
providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations.
Unless required by law, there will be no other uses and disclosures of this information without my authorization.
 That Illinois Gastroenterology, LLC /Mid-Central Illinois Gastroenterology , Ltd, a member of Premier Medical Group, LLC
has a detailed document called the 'Notice of Privacy Practices'. It contains a more complete description of your rights to
privacy and how we may use and disclose protected health information.
 That I have the right to read the 'Notice' before signing this agreement. If I ask, Illinois Gastroenterology, LLC /Mid-Central
Illinois Gastroenterology , Ltd, a member of Premier Medical Group, LLC will provide me with the most current Notice of
Privacy Practice.
 That Illinois Gastroenterology, LLC /Mid-Central Illinois Gastroenterology , Ltd, a member of Premier Medical Group, LLC, a
member of Premier Medical Group, LLC policy is to call patients by their first and last names.
My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature
means that I agree to allow Illinois Gastroenterology to use and disclose my protected health information to carry out treatment,
payment, and health care operations, including release of medical information to my insurance/Medicare carrier to determine
benefits payable for related services. I understand that I am financially responsible to the clinic for any charges covered by this
authorization. Some costs (i.e. immunizations, Virtual Colonoscopy's) may not be covered by insurance/Medicare. I understand that
these costs are my responsibility. I have the right to revoke this consent in writing at any time, except to the extent that Illinois
Gastroenterology has taken action relying on this consent.
________________________________________________________
SIGNATURE (Patient or Legal Custodian/Authorized Representative)
________________________________________________________
PRINT NAME
___________________
DATE
___________________
Relationship to Patient
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our 'Notice' at anytime by contacting : Illinois Gastroenterology, LLC, 2200
Jacobssen Drive, Normal, IL., 61761 309-451-1123
*ADDITIONALLY, you grant Illinois Gastroenterology, LLC/Mid-Central Illinois Gastroenterology, Ltd Permission to leave a message
on your answering machine and/or voice mail.
YES
or
NO
(This would be the phone number recorded in the chart unless another one is specified)
Permission to discuss your health care issues with your spouse or other
designated person.
YES
**If yes, please list additional designated individuals:
Relationship to patient
_________________________________________
__________________
_________________________________________
__________________
or
NO
Phone Number
_____________________
_____________________
2014
ILLINOIS GASTROENTEROLOGY, LTD.
NAME: _______________________________DATE: __________________________
REASON FOR VISIT: ___________________________________________________
PATIENT Illness/Surgery
Year
Do you smoke?  Yes  No
__________________
_____
# Packs per day: _________
# Years smoked: _________
__________________
_____
__________________
_____
__________________
_____
__________________
_____
Do you use alcohol?  Yes  No
# drinks per week: ____________
MEDICINES: (List all prescriptions
over-the-counter drugs, vitamins,
herbal, etc.):
FAMILY History
Disease
Relationship






__________
__________
__________
__________
__________
__________
Cancer
Colon Polyps
Ulcer
Liver Disease
Pancreatitis
Other
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
ALLERGIES:
Drug: _____________________
_____________________
_____________________
Other: ____________________
____________________
MID-CENTRAL ILLINOIS GASTROENTEROLOGY, Ltd
GASTROINTESTINAL INSTITUTE, LLC
2200 Jacobssen Drive
Normal, IL 61761
Illinois Gastroenterology and Gastrointestinal Institute prides itself for the close relationships we have with
our patients. But we may not be sure, in every case, whether a family member or friend is involved in your
care. We ask that you complete this form to inform us of those individuals. We will enter this
information in our computer system to assist our staff in verifying a person’s involvement. By identifying
your caregivers, you can avoid problems that may arise when our staff does not know a person’s
relationship to you and your care. This form does not address individuals who are involved in the payment
to your health care services, such as guarantors.
Patient Name: ___________________________________________________ Date of Birth:___________
Patient Address: _________________________________________________ SS# ___________________
By completing this form and signing below, you are granting Illinois Gastroenterology/Gastrointestinal
Institute permission to share protected health information (PHI), including without limitation, appointment
information, test results, diagnosis, or treatment plans, with the individual(s) listed below who is/are a
family member, close friend, or other person involved in you care. Under certain medical circumstances,
however, a licensed health care professional may identify one or more individuals after determining in
his/her professional judgment that sharing PHI on a continual basis would be in the best interest of that
patient (e.g. emergency situations, patient has Alzheimer’s and no power of attorney was granted to the
caregiver, etc.). There may be other medical situations where the Practice may disclose PHI to family
members or friends in accordance with federal or state law. Categories of people will not be accepted (e.g.)
“all family members” or “all members of your church”) because
of the difficulty in verifying their identity.
Name
Relationship
Address and Phone Number
____________________ _________________
________________________________
____________________ _________________
________________________________
____________________ _________________
_______________________________
____________________ _________________
______________________________
Patient Signature (required):_______________________________Date:______________
Staff Signature (if applicable): _____________________________Date:______________
Mail completed form to Illinois Gastroenterology, Ltd, 2200 Jacobssen Drive, Normal,
IL. 61761
PATIENT NAME: ____________________________
ILLINOS GASTROENTEROLOGY, LTD.
a member of Premier Medical Group, LLC
REVIEW OF SYSTEMS
CONSTITUTIONAL
Recent Weight Loss
Fever
Fatigue
□ Yes □ No
□ Yes □ No
□ Yes □ No
EYES
Blurred Vision
Glaucoma
□ Yes □ No
□ Yes □ No
EARS/NOSE/MOUTH/THROAT
Recent hearing loss
□ Yes □ No
Mouth sores
□ Yes □ No
GASTROINTESTINAL
Poor appetite
Difficulty in swallowing
Heartburn
Nausea or vomiting
Bloating
Belching
Regurgitation
Constipation
Diarrhea
Abdominal pain
Recent change in bowel habits
Rectal Bleeding
Black, tarry stools
□
□
□
□
□
□
□
□
□
□
□
□
□
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
□
□
□
□
□
□
□
□
□
□
□
□
□
No
No
No
No
No
No
No
No
No
No
No
No
No
□
□
□
□
Yes
Yes
Yes
Yes
□
□
□
□
No
No
No
No
CARDIOVASCULAR
Chest pain
Shortness of breath
Swelling of ankles
□ Yes □ No
□ Yes □ No
□ Yes □ No
NEUROLOGICAL
Headaches
Seizures
Strokes
Numbness
RESPIRATORY
Chronic cough
Coughing up blood
Wheezing
□ Yes □ No
□ Yes □ No
□ Yes □ No
PSYCHIATRIC
Memory loss or confusion
Depression
□ Yes □ No
□ Yes □ No
GENITOURINARY
Burning with urination □ Yes □ No
Blood in urine
□ Yes □ No
ENDOCRINE
Heat or cold intolerance
Excessive thirst or urination
□ Yes □ No
□ Yes □ No
MUSCULOSKELETAL
Joint pain OR
Back pain
Muscle pain
□ Yes □ No
□ Yes □ No
□ Yes □ No
HEMATOLOGICAL
Bleeding or bruising tendency □ Yes □ No
Anemia
□ Yes □ No
Past transfusion
□ Yes □ No
SKIN
Rash
Itching
□ Yes □ No
□ Yes □ No
Are you pregnant?
□ Yes □ No
Have you seen/heard
our TV/radio ads?
□ Yes □ No
Gastrointestinal Institute, LLC.
Illinois Gastroenterology, Ltd.
a member of Premier Medical Group, LLC
NOTICE:
2200 Jacobssen Drive
Normal, IL 61761-5516
Office: 309.451.1123
EFFECTIVE JANUARY 1, 2015
CANCELLATION AND NO SHOW POLICY
We understand that situations arise in which you must cancel your appointment. It is therefore
requested that if you must cancel your appointment you provide more than 24 hours notice.
This will enable for another
person who is waiting for an appointment to be scheduled in that appointment slot. With
cancellations made less than 24 hours notice, we are unable to offer that slot to other people.
Office appointments which are cancelled with less than 24 hours notification may be subject to
a $50.00 cancellation fee. Procedure cancellations require 3 business days advance notice,
without notification they may be subject to a $150.00 cancellation fee.
Patients who do not show up for their appointment without a call to cancel an office
appointment or procedure appointment will be considered as NO SHOW. Patients who NoShow two (2) or more times in a 12 month period, may be dismissed from the practice thus
they will be denied any future appointments. Patients may also be subject to $50.00 fee for
office appointment No Show and $150.00 procedure No Show fee.
The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in
full before the patient's next appointment.
We understand that Special unavoidable circumstances may cause you to cancel within 24
hours. Fees in this instance may be waived but only with management approval.
Our practice firmly believes that good physician/patient relationship is based upon
understanding and good communication. Questions about cancellation and no show fees
should be directed to the Billing Department (309) 451-1123.