Patient Forms

Dear Patient,
In order to meet the highest standards regarding your care, and to stay in compliance with the latest government regulations, we have prepared this packet which contains important information regarding your visit to IMA Endoscopy SurgiCenter.

• Patient’s Rights and Responsibilities
• Ownership of the SurgiCenter
• Advanced Directive Policy

Please review this material, sign and date where indicated prior to your procedure date, and bring it with you on the day of the procedure. We are required by the federal government to have these signed documents in your medical record prior to performing any procedures.

If time allows, you may mail these signed documents to our office at the address below. Otherwise, you must bring them on the day of the procedure. You will also be receiving a phone call from one of our staff nurses who will review all of this information with you. This phone call will also allow you the opportunity to discuss or ask any questions.

On behalf of the physicians and staff at IMA Endoscopy SurgiCenter, we thank you for choosing us and look forward to meeting you.

IMA Endoscopy Surgicenter
Attn: Medical Records
8895 Broadway
Merrillville, IN 46410

Sincerely,
Dawn M. Bailey, R.N.
Clinical Director/Administrator

For your convenience, our registration forms are also available online: