general surgeon peoria il

Office/Appointment Info

Patient Guide

Appointments

Mid Illini Surgical Associates is by appointment only!

Rescheduling  and Canceling Appointments

If you need to cancel, or reschedule, your appointment for any reason, please notify our office as soon as possible (309) 672-5975, or 800-706-6472

Emergency: After Hours

In the event of an emergency after office hours, our answering service will relay your message to the physician on call.  Please call (309) 672-5975.


PATIENT GUIDE

1. Complete "Patient Packet" and bring with you at your appointment. 
The packet will include:
a. patient demographics
b. health information form
c. health consent privacy practice
c. review of systems

You may receive by mail, or obtain from this website

2. Bring a current list of all medications/dosages and how often you take your meds.  Please include all over the counter prescriptions as well.

3. Picture Identification Card

4. Health Insurance Card - know preferred plan providers (i.e. hospital).

5. Be prepared to pay co-payment.

6. Uninsured - a $125 "partial payment" towards the cost of services will be expected at your office visit. You are welcome to pay with cash, or credit card.  If you are unable to meet these requirements, please call the office and make arrangements PRIOR to your scheduled appointment.

ANY please feel free to contact our office!
 (309) 672-5975

Insurance

Mid Illini Surgical Associates participates with most networks and carriers. 

Below is a listing of a few carriers and networks:

  • 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 or network is not listed, please contact your insurance company to confirm that MiSA is a participating provider.

As a “participating provider” for most carriers and networks, Mid Illini Surgical Associates’ contract requires that we “collect co-payments at the time of each visit”. 

Your Responsibilities include:

  1. Know your co-payment amount (listed on insurance card)
  2. Know Pre-Authorization requirements
  3. Know participating hospital(s)

Your health is the utmost important to us and we want you to receive the maximum benefits.  We do our best to stay up to date with all the plans, policies, and procedures – working together by knowing “your” plan will help you achieve the maximum benefits.  

Billing

Mid Illini Surgical Associates will bill all insurance carriers.

It is the patient's responsibility to provide all accurate and current information regarding their insurance.
Patients will receive a statement once the carrier(s) respond.

Uninsured patients are responsible for making a partial payment at his/her first office visit while making future arrangements PRIOR to appointment. 

Arrangements that are NOT made may result in the need to reschedule your appointment until payments arrangements can be successfully arranged.

 We encourage you to communicate with our Billing Department should you have any questions regarding payments, or billing.
Thank You!
(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