general surgeon peoria il

Office/Appointment Info

Patient Guide

Appointments

Mid Illini Surgical Associates sees patients by appointment only. To better serve our patients, a reminder phone call will be placed a few days prior to your appointment.  

Rescheduling  and Canceling Appointments

If you need to reschedule or cancel your appointment for any reason, please notify our office as soon as possible.  Call:  (309) 672-5975    

Emergency: After Hours

A physician is on call everyday after hours.  In the event of an emergency after office hours, our answering service will assist you in contacting the on call physician.  Call:  (309) 672-5975


PATIENT GUIDE

1. Park in the Atrium Street Level Lot located on Globe or use Methodist Parking Deck 2 located off Hamilton Street -- parking is free to all patients/visitors.

2. Bring a current list of all medications including doses and frequency taken.  Please include all over the counter medications taken as well.

3. Bring a Picture Identification Card

4. Bring your Health Insurance Card - be familiar with the benefits of your plan and what hospital(s) you can use.

5. Be prepared to pay co-payment. 

6. Uninsured patients - a $125 "partial payment" towards the cost of services will be expected at the time of your office visit. 

Mid Illini Surgical Associates accepts cash, check and credit/debit cards.  

If you are unable to meet these requirements your appointment could be affected.  Please call our office and make payment arrangements PRIOR to your scheduled appointment.

Please call our office with any questions 
 (309) 672-5975

Insurance

Mid Illini Surgical Associates participates in most major insurance programs and will bill your insurance carrier for you after services are rendered.  As an additional courtesy to you, we will assist with completing prior authorization and pre-certifications with your primary insurance company during your visit. 

MiSA participates in the following major insurance plans:

  • Blue Cross Blue Shield of Illinois
  • Cigna
  • First Choice
  • Health Alliance
  • Health Plus
  • Humana
  • Medicare
  • PHCS
  • UMR
  • United Health Care
  • United HealthCare of the River Valley


If your carrier is not listed, please contact your insurance company to confirm that MiSA is a participating provider.

Mid Illini Surgical Associates collects co-payments at the time of service.

Your Responsibilities include:

  1. Know your co-payment amount
  2. Know Pre-Authorization requirements for tests and/or surgery
  3. Know the hospital(s) that you can use for services
  4. Ensure that we have your most current insurance information

Your health is important to us and we want you to receive the maximum benefits from your insurance plan.  We do our best to stay up to date with  plans, policies, and procedures, but ultimately it is the patient's responsiblity for knowing their individual plan, coverage and requirements. It is the patient's responsibility for co-pays, deductibles and any balance not covered by insurance.

Billing

Mid Illini Surgical Associates will submit a payment claim for services received to the patient's insurance company as a courtesy.  It is the patient's responsibility for co-pays, deductibles and any balance not covered by insurance.  Patients will receive statements for any balance due on their account once their insurance carrier has processed submitted claims.

* It is the patient's responsibility to provide all accurate and current information regarding insurance and be aware of the benefits & coverage of the insurance plan.  Inaccurate information may affect the insurance carrier's payment for services received.

Uninsured patients are responsible for making a partial payment for their first office visit.   Further payment arrangements will be discussed with you by our billing department for office visit balances and any other services that may be needed.

Payment arrangements that are NOT made may result in the rescheduling or canceling of your appointment until payments can be successfully arranged.

 If you have any questions regarding payments or billing, please contact our billing/insurance department at
(309) 672-5975

Patient Registration Form

Patient Name
E-Mail Address
Social Security No
Sex
Male     | Female
Marital Status
Address
City
State
Zip Code
Date of Birth
Home Phone
Cell Phone
Other Numbers (If Any)
May We Call / Leave a Message?
Yes     | No


Patient's Employer
Employer's Address
Work Phone
May We Call / Leave a Message?
Yes     | No


Name of Spouse / Parent
Spouse / Parent Social Security No
Address
Spouse / Parent Date of Birth
Spouse / Parent's Employer
Address of Spouse / Parent's Employer
Phone Number of Spouse / Parent's Employer


Emergency Contact Name
Emergency Contact Number


Primary Insurance Information

Insurance Company Name
Policy Holder
Policy Holder Social Security No
Policy Holder Date of Birth
I.D. No or Policy No
Group No
Policy Holder Employer


Secondary Insurance Information

Do you wish to provide secondary insurance information?
Yes     | No


Workman's Comp / Liability Information

Is This a Work Injury or Automobile Accident?
Yes     | No


NOTE: We must have a copy of your insurance card before any surgery can be scheduled.



Please list any family members that have ever been treated by our doctors:
Name Year Doctor


Privacy Regulations

The Federal HIPAA act requires that we are prohibited from releasing your health information to anyone, other than physicians, without your prior approval. Please list anyone we may release information to regarding your care by Drs. Esch, Wieland and Naour.

Name Relationship

Social History

Use of Tobacco
Yes
No
Previously, but quit
Use of Alcohol
Never
Rarely
Moderately
Daily
Use of Recreational Drugs
Never
Rarely
Previously, but quit
Do you currently reside in an assisted living facility or nursing home?
Yes
No    


Surgical History

Date Procedure


Problems with anesthesia


Allergies

Please list any allergies you may have to drugs, over the counter drugs, food, and environmental allergies.


Current Medications

Medication Reason For Taking Dosage / Times Per Day Perscribing Physician


Primary Care Physician
Last Seen
Other Physicians (if any)
Reason For Signing Up

Medical History

Constitutional Systems
Recent weight change
Yes     | No
Fever
Yes     | No
Glaucoma
Yes     | No


Ears/Nose/Mouth/Throat
Chronic sinus problem
Yes     | No
Nose bleeds
Yes     | No


Cardiovascular
Heart murmur
Yes     | No
Mitral valve prolapse
Yes     | No
Rheumatic fever
Yes     | No
High/low blood pressure
Yes     | No
Palpitation
Yes     | No
Congestive heart failure
Yes     | No
Pacemaker/AICD
Yes     | No
Irregular pulse
Yes     | No
Heart attack
Yes     | No
Swelling of feet, ankles, or hands
Yes     | No
Heart disease
Yes     | No
Coronary angiogram
Yes     | No
Heart surgury
Yes     | No
Peripheral Vascular Disease
Yes     | No


Respiratory
COPD
Yes     | No
Emphysema
Yes     | No
Asthma
Yes     | No
Shortness of breath while walking or lying flat
Yes     | No
Wheezing
Yes     | No
Pneumonia
Yes     | No
Use Oxygen
Yes     | No
Sleep apnea
Yes     | No


Gastrointestinal
Abdominal Pain
Yes     | No
Nausea / vomitting
Yes     | No
Frequent Diarrhea
Yes     | No
Change in Bowel Movement
Yes     | No
Painful bowel movement or constipation
Yes     | No
Rectal bleeding / blood in stool
Yes     | No
Stomach ulcer
Yes     | No
Liver disease
Yes     | No
Jaundice
Yes     | No
Hepatitis
Yes     | No
Hemorrhoids
Yes     | No


Genitourinary
Incontinence or dribbling
Yes     | No
Kidney stones
Yes     | No
Hysterectomy or tubal
Yes     | No


Musculoskeletal
Arthritis
Yes     | No


Integumentary (skin / breast)
Varicose veins
Yes     | No
Breast pain
Yes     | No
Breast lump
Yes     | No
Breast discharge
Yes     | No
Date of last mammogram
Where


Psychiatric
Nervousness
Yes     | No
Depression
Yes     | No


Neurological
Frequent or recurring headaches
Yes     | No
Convulsions / Seizures
Yes     | No
Tremors
Yes     | No
Dementia / Memory loss
Yes     | No
Stroke (RIND/TIA)
Yes     | No
Migraines
Yes     | No


Endocrine
Diabetes
Yes     | No
Thyroid disease
Yes     | No
Kidney disease
Yes     | No
Kidney failure hemodialysis or CAPD
Yes     | No


Hematologic / Lymphatic
Bleeding / bruising tendency
Yes     | No
Anemia
Yes     | No
Phlebitis / blood clots in legs
Yes     | No
Cancer, chemo, or radiation
Yes     | No
HIV positive
Yes     | No


Date of most recent bloodwork
Location


Date of most recent EKG
Location


Date of most recent chest X-ray
Location

Agreement

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I authorize the healthcare staff to perform the necessary services I may need and release information to others if necessary for my care.

I Agree