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Notice:

Bloomington
Endoscopy Center:
Your Right To
Know

BEC Provider Listing

East Walk-In Clinic

2605 East Creek's Edge Drive
Monday-Friday, 3pm-7pm
Seeing patients 13 years or older.

East Laboratory
Monday - Friday, 8am-5pm
Anti-coagulation Clinic Patients
will only be seen at IMA Landmark

Landmark Walk-In Clinic

550 Landmark Avenue
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

Patient's
Bill of Rights

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.       Anderson, NP Bannec Behn Benson Bhandari Bomba Jr. Burkholder Burns, NP Chang Cohen Dayton H. Dukes R. Dukes Faris Ferguson Fields, N.P. Fix Florini German Ghosh Hamilton Hartung J.D. Headdy Jacobs, N.P. Henrich Heumann F. Hrisomalos T. Hrisomalos Hullinger Hummel David Joyce Jacqueline Joyce Kumar LaFollette, C LaGrange Orth Penrose, NP Petersen Pinto Porvaznik Ratliff Rink Selo Smith, N.P. Stolz, N.P. Strobel Sutliff Thompson Touloukian Eric 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