Billing Profile Changes

If you have insurance or other account information changes that you would like to inform us about, you can contact us by telephone at 217.528.7541 or 800.444.7541 Monday through Friday, or you can update your account online by completing the online form below.

To use the form, please complete all applicable fields to ensure the accuracy of the updated information. If you do not understand a particular prompt, simply move your cursor over the blue symbol next to the field for a brief explanation of that data element. Account changes will be updated to your billing profile within one business day of submission.

*Please note, a signature is required on all forms before submission.

Authorization for Release of Medical Information

Authorization for Release of Medical Information – The authorization for release of information is needed for hard copy medical records.

Notice for Revocation Authorization Form

Notice for Revocation Authorization Form - Filled out when a patient chooses to revoke a previously completed authorization.

Special Billing Form

Special Billing Form - Filled out by the patient when the claim for services they are receiving that day are not to be billed to the patient’s regular health insurance (work injury, automobile injury, personal liability injury). A signed copy of this form is to be given to the receptionist at each doctor’s visit as well as to each provider of ancillary services such as laboratory, x-ray or physical therapy.

Statement of Extended Family Billing Agreement

Statement of Extended Family Billing Agreement - Form to be completed when the patient, who is no longer a minor, chooses to remain on their parent's account.

Verbal Authorization Form

Verbal Authorization Form - This authorization must be signed by the patient in order for Springfield Clinic to speak with specified individuals about the patient's account or medical information. (en Español)