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Walk In Clinic

Monday-Friday, 8am-6pm
Saturday, 9am-12noon
Sunday, 1pm-4pm
No appointment necessary

Laboratory Hours:
Monday-Friday, 7am-6pm
Saturday, 8am-12noon
No appointment necessary

IMA Research

Internal Medicine
Associates
Notice of
Privacy Practices

Bloomington
Endoscopy Center
Notice of
Privacy Practices

Personal Information E-mail Security Disclaimer: The form on this page is sent through e-mail, which is not a secure method of communication. If you would rather not take the risk of sending personal information by this format, please contact our office at 812-355-6900. By using any of our e-mail functions, you acknowledge that you have read this notice and agree to the "risks." IMA requires information marked with an * to contact you. Your social security number is not required, but does assist IMA in tracking your records.

First Name*

Middle Initial

Last Name*

*Select your Medical Provider. This is required.       Alpert Bannec Behn Bhandari Bomba Jr. Burns, NP Chang Cohen Dayton Dukes Faris Fields, N.P. Fix Florini German Ghosh Hamilton J. Headdy, PT J.D. Headdy Henrich Heumann F. Hrisomalos T. Hrisomalos Hullinger Jerrells David Joyce Jacqueline Joyce Kumar Lafollette Lee, N.P. Cristen Mazzella Danilo Mazzella O'Neill Orth Petersen Pinto Porvaznik Ratliff Reddy Rink Sharp Smith, N.P. Stolz, N.P. Strobel Sutliff Thompson Touloukian Eric Trueblood Jackie Trueblood

Phone Number*

Date of Birth

Social Security Number

Are you currently a patient? Yes    No

If you are a new patient, who referred you to IMA?

If different from your referrer, what is the name of your Primary Care Physician?

Insurance Information

Name of Insurance Company

Phone number of Insurance Company

Do you need pre-approval from your insurance company for this visit?    Yes    No

Do you have Medicare?    Yes    No

If so, what is the name of your secondary coverage provider?

Nature of visit

Day of visit

Preferred

Second Choice