New Patient Packet 2024

Diamond Gastroenterology
Ilysa Diamond, DO
1010 Lake Street
Suite 424
Oak Park, IL 60301

Phone: (708)613-4417
Fax: (708)613-4267
www.diamondgi.net
Patient Registration Form
Patient Name (Last, First, Middle)*
DOB*

MonthDayYear
Date
Gender
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State*
Zip*
Mobile Phone*
Work Phone
Social Security Number
Email
Primary Insurance Information
Insurance Name*
ID*
Group*
Subscriber Name (Last, First, Middle)*
Subscriber DOB*
Relationship to patient*
Subscriber Social Security Number
Same as above?
Emergency Contact
Contact Name (Last, First, Middle)*
Relationship*
Mobile Phone*
Work Phone
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
No-Show, Late, Cancellation Policy
This policy has been established to help us serve you better. It is necessary for us to make appointments in order to see our patients as efficiently as possible. When an appointment is missed it takes an available time slot away from another patient, as well as delays the delivery of health care to other patients, some who are quite ill.

A "no show" is missing a scheduled appointment without informing us. A "late cancellation" is canceling an appointment without calling us 48 hours in advance for a scheduled visit or procedure.

We also ask that you arrive promptly to your scheduled appointment. We understand that certain situations occasionally arise and a courtesy call is greatly appreciated. If you arrive after your scheduled check-in time, you may be asked to reschedule your appointment to a later time or date. We feel our patient's time is valuable and we do this only to offer quality care to all our patients, including you.

Our No-show and Late Cancellation Fee is:

$60 For a "Scheduled Visit" without calling us to cancel 48 hours in advance or 15 minutes after your set time.

OR

$150 For a "Scheduled Procedure" without calling us to cancel 48 hours in advance.

Please sign that you have read and agree to the policy above:
Name*
Date*

MonthDayYear
Signature*

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Date*

MonthDayYear
CONSENT FOR PAYMENT
1. Responsibility for payment. I agree that I am financially responsible for all services provided to me. I acknowledge that I may receive separate bills for services provided. If I choose to have my health insurance cover my treatment, I authorize Dr. Diamond to bill any such insurer for all medical services and products provided. My insurance may provide that some amount of the bill will remain my personal responsibility, such as my deductible, co-payment or charges not covered by my health insurance. In addition, I understand that my insurance company may have placed restrictions on my health insurance coverage, services, facility and/ or provider which must be satisfied prior to treatment except in emergency situations. I understand that if Dr. Diamond, my treating physician is restricted by my insurance as out of network provider, I may be responsible for additional charges. Any questions I have regarding my health insurance coverage should be directed to my health plan.
2. Assignment of benefits. I hereby assign, transfer, and set over all direct payment to Dr. Diamond of any insurance or health plan benefits otherwise payable to me or on my behalf. I understand that I am responsible for all charges not covered by this assignment.
  
  If I claim benefits under the Title XVIII of the Social Security Act (Medicare), I hereby certify that the information I provide in applying for payment of such benefits is correct, and I authorize release of any of this information needed to act on this request. I understand that I am responsible for all changes not paid for by Medicare.
  
  I have read and certify that I have an opportunity to discuss the contents thereof to my satisfaction. By signing this form, I am consenting to the medical and/or surgical treatment(s) or procedure(s) which may be performed during this office visit with Dr. Diamond.
Patient Signature*

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Time*
Date*

MonthDayYear
Patient Representative

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Time
Date

MonthDayYear
GENERAL CONSENT FOR TREATMENT
1. Consent for Diagnosis, Care and Treatment I, the undersigned, hereby consent to the medical and surgical treatment(s) which may be performed.
2. Release of Information. I authorize my treating physician to release my records, including my sensitive health information, to any person or entity which is or may be responsible for all or any portion of treating physician's charges, including, but not limited to insurance companies, healthcare service plans, worker's compensation carriers, medical or utilization review organizations designated by any of the foregoing, or to any person or entity as necessary in connection with such payment of reimbursement.
  
  I authorize Dr. Diamond to release and/or send copies of medical record to my referring physician(s) and to physician(s)who may be involved in my future care, as necessary for treatment, continuity of care.
Patient Signature*

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Time*

Hour Minutes

AM/PM Option
Date*

MonthDayYear
Date
Patient Representative Signature

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Time

Hour Minutes

AM/PM Option
Date

MonthDayYear
Date
Reason for todays visit*
Allergies
Medical History

DiabetesHigh Blood PressureAnemiaCholesterolBlood ClotsHeart DiseaseBipolar and/or SchizophreniaTyroidDepressionCancerOther
History of Cancer
Family Medical History

Colon CancerStomach CancerEsophageal CancerUlcerative ColitisCrohn's Disease
Medication List Name Dosage
Are you taking any Anticoagulants (blood thinners)

YesNo
Please specify:

PlavixCoumadinAspirinXareltoEliquisLovenox
Have you had any surgeries?

YesNo
Please specify:

Hysterectomy (uterus)C-sectionCholecystectomy (gall bladder)BowelOther
Do you smoke?

YesNo
If yes, do you wish to quit?

YesNo
Do you drink alcohol?

YesNo
If yes, how many drinks per week?
Do you do Recreational Drugs?

YesNo
If yes, which one?
Primary Care Physician
Name

First NameLast Name
Address
Phone Number
Please enter a valid phone number.
Fax
Preferred Pharmacy
Name*
Zip Code*
Have you ever had any of the following

YesNo
If yes, which one(s)?

ColonoscopyEGDUltrasound of Abdomen or PelvisCT ScanRecent Bloodwork
If so, please email to info@diamondgi.net.
ROS
Do you have any of the following?

FatigueFeverNight SweatsWeight lossAnxiety/DepressionJoint PainDizzinessHorsenessChest PainSores in mouthArthritis PainWeight GainShortness of BreathAbdominal PainCoughSwelling in legsConstipationTrouble Breathing while Lying DownPalpationBlood in StoolBlack StoolDiarrheaGas/burpingProblems SwallowingHeartburnLump in ThroatSnoringNauseaVomitingAlways Thirsty
State ID or Driver's License

Cancelof
Insurance Card (front and back)

Cancelof
Should be Empty:

Patient Registration Form

Primary Insurance Information

Emergency Contact

No-Show, Late, Cancellation Policy

CONSENT FOR PAYMENT

GENERAL CONSENT FOR TREATMENT

Primary Care Physician

Preferred Pharmacy

ROS