Thank you for choosing North Suburban Gastroenterology Associates for your new patient visit. We look forward to seeing you and discussing your particular medical condition. We want you to feel comfortable coming to our office.
For your convenience, we have patient data forms that you may download and complete at home. You must bring these with you at the time of your first visit. Be assured that confidentiality of our patient’s health records has always been a priority in our office.
Please bring all your completed, signed forms and your INSURANCE CARDS at the time of your visit.
|Download the Portable Document Format (PDF) documents below. To view and print these documents, you will need Adobe Reader
Complete and bring the following:
- Patient Registration (PDF)
- Privacy Statement – federally mandated by HIPAA, 2 pages (PDF)
- Written Disclosure (PDF)
- Medication Flowsheet (PDF)
- Review of Systems – 2 pages (PDF)
- Consent for Release of Information for Treatment, Payment and Healthcare Operations (PDF)
- Insurance cards. NOTE: If you are part of an HMO, EPO or POS, you must obtain your referral or authorization prior to seeing us. Bring it with you at the time of your visit. CO-PAYS are due at the time of your visit.
Please review our financial policies:
- Financial Policy (PDF)
- Screening Colonoscopy (PDF)
Thank you for your cooperation in these very important matters. If you have any questions regarding these policies, please call our office at 847-696-3176 or 847-696-3178. Questions regarding financial matters may be addressed to our billing office at 847-696-2336. We look forward to continuing to provide all of our patients the highest quality gastrointestinal services.