THE ILLINOIS CENTER FOR DIGESTIVE AND LIVER HEALTH
22285 N. Pepper Rd.
LAKE BARRINGTON IL 60010
PH: 847-382-7165 FAX: 847-713-8160
Welcome to our practice! We hope the following information will be helpful to you. We respect your time and we would like to make your visit to our office as efficient as possible.
Location:
Financial Policy:
We collect copays at the time of service. If you have questions, please do not hesitate to contact the patient account representative at 847-382-7165
Medical Insurance:
We will file for insurance reimbursement on your behalf. Your reimbursement may not cover the full cost of your services. Regardless of insurance, payment remains your personal responsibility.
Cancellation / No‐Show:
Our office sees patients by appointment only. If you are unable to keep your appointment, please notify us at least 24 hours in advance, so that we are able to offer the time to another patient. No‐show, cancellation and rescheduling for office appointments must be at least 24 hours in advance or you will incur a $50 fee, which will not be applied to any copay, deductible or coinsurance.
Privacy Notice:
A copy of the Privacy Notice has been enclosed.
Checklist of items to bring to your visit
Patient Information & Signed Authorizations
Current Insurance card and photo ID
Insurance referral if needed
Financial Policy
Medical Information & Signed Patient Statement
If you are being referred for any abnormal labs or radiology findings you must bring a copy of the report with you to the office visit. Although you may have requested them from your referring doctor, they often times do not reach our office prior to your visit.
If you have any questions regarding the above, or if we can be of further help, please do not hesitate to call our office at 847-382-7165.
We look forward to meeting you.
THE ILLINOIS CENTER FOR DIGESTIVE AND LIVER HEALTH
PATIENT DEMOGRAPHIC INFORMATION
FINANCIAL POLICY
Welcome to The Illinois Center for Digestive and Liver Health, and thank you for choosing us! We appreciate your confidence and goodwill. To ensure that we have financial stability and can continue to provide medical services to the community and region, the following policies shall be enforced:
Uninsured Patients:
· All Charges are due and payable at the time of service. We accept cash, check and major credit cards. We may reschedule the appointment if payment is not made prior to the service rendered.
Patients with insurance:
· The physicians will bill insurance plans as a courtesy to their patients if the patient provides the required insurance information at the time of service and signs the assignment of benefits statement. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover. While the filing of insurance claims is a courtesy that we extend to patients, all charges are your responsibility from the date the services are rendered.
· It is the patient’s responsibility to determine whether a referral is required, and the referral can be requested from your primary care physician. If we have not received an authorization prior to your arrival at the office, we have a telephone available for you to call your primary care physician to obtain it. If you are unable to obtain the referral at that time you will have the option of paying for your visit or rescheduling.
· If the patient’s insurance rejects, denies or covers only a portion of treatment, the patient shall be responsible for immediate payment of the balance due. A pre‐treatment deposit may be required.
No‐Show and Cancellation Policy:
· If the patient fails to cancel his/her procedure at least 5 business days in advance or is a no‐show, the patient is responsible for $250 fee which will not be applied to any copay, deductible or coinsurance. If the patient cancels or reschedules for an office appointments without giving a 24 hour notice the patient is responsible for a $50 fee, Also if the patient no-shows for their appointment the patient will be responsible for a $50 fee which will not be applied to any copay, deductible or coinsurance.
· If the patient reschedules within 48 hours of his/her procedure, the patient is responsible for $75 fee which will not be applied to any copay, deductible or coinsurance.
· If the patient reschedules within 24 hours of his/her procedure, the patient is responsible for $150 fee which will not be applied to any copay, deductible or coinsurance.
Delinquent / Unpaid Account:
· Prior to providing services, payment of prior outstanding accounts will be requested and should be received. Patients with unpaid delinquent accounts or accounts which have been written off to bad debt may be denied treatment if not medically urgent.
· Accounts which cannot be collected by the physician after normal in‐house collection procedures may be referred to a collection agency, magistrate or attorney for further collection action in accordance with the established guidelines. All delinquent accounts over 90 days will incur a service fee. Accounts referred to collection will also incur a collection fee. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within (30) thirty days of billing.
Refunds:
· Overpayments will be refunded to the appropriate party, normally the insurance company or guarantor. Patients’ refunds will not be processed until all active or past due accounts are paid in full.
Insurance / Disability Forms:
· There will be a $25 handling fee to cover the administrative fee for writing a letter or filling out claims forms, such as insurance forms or disability forms (except Medicare patients). The fee is due once the form is completed, and the patient will be directly responsible for this fee.
Returned Checks:
· Checks returned to The Illinois Center for Digestive and Liver Health, PC for insufficient funds, closed account, stopped payment, or any other reason will be subject to a $25 fee.
Fees for Service:
· For specific information pertaining to fees for service please consult with our Billing Manager.
Medical Records:
· Illinois state rates apply for processing medical records per Code of Civil Procedure 735 ILCS 5/8-2001(d): Handling fee of $27.91; Copy pages 1 through 25 $1.05; copy pages 26 through 50 $0.70; copy pages in excess of 50 $0.35; copies made from microfiche or microfilm $1.74.
Patient Rights and Responsibilities
Your rights: (You have the right to..)
· Be treated with respect and dignity.
· Have your privacy protected.
· Have your beliefs and values respected.
· Have your spiritual needs and your family’s spiritual needs met.
· Ask and talk about the ethics of your care.
· Have your wishes about organ donation followed as well as DNR order.
· Have your doctor and a family member or person that you choose told when you are admitted to the hospital.
· Receive information in a way you understand.
· Be involved in all aspects of your care.
· Know the names and credentials of your health care providers.
· Receive information about the results of your care.
· Receive care to make you as comfortable as possible.
· Ask for and receive a copy of your health records within a reasonable amount of time.
· Ask for and receive an itemized bill and be able to ask for explanations.
· Tell staff members if you have a complaint or concern.
· Have the right to change providers.
· Contact an on-call provider after hours through our answering service prompt.
· Report a complaint/grievance. - ** please report all complaints/grievances to Director of Operations.
Amber Fallico E: amber@icdlh.com.
Your Responsibilities: (You are responsible for..)
· Providing your providers with accurate and complete information about your medical history.
· Telling your provider if there is a change in your condition.
· Telling your provider if you have a reaction to treatment, worsening pain or symptoms.
· Providing our office with copies of Advanced Directives.
· Telling staff members right away if you feel your rights have been violated.
· Providing accurate insurance information.
· Asking questions if you do not understand or agree upon your plan of care.
· Following the instructions from your health care provider.
· Accepting the results if you refuse treatment or if you do not follow the instructions from your health care provider.
· Keeping appointments.
· Following the requests made by our staff and providers to ensure safety and appropriate care/behavior.
· Respecting staff, providers, and other patients.
If you have any questions or concerns please mention to our Patient Access Representatives and they will direct you to the correct party.