Forms and Policies

Forms and Policies

LCM Medical Forms and Policies

Your Personal Information

LCM Medical Group values your privacy. We follow all HIPAA guidelines and regulations. Click here to read our Privacy Act.

 

 

Patient Registration

Patients are required to provide certain information during registration in order for our office to provide treatment and bill insurance for our services. Upon arrival at our office, please have insurance cards and copayments available. New patients may print and complete registration forms prior to scheduled appointment. New Patient Registration Form

 

 

Questionnaire for Medicare Annual Wellness Exam

*Please print and fill out this questionnaire and bring it to with you to your next wellness appointment!

 

 

Medical Record Release of Information 

To access your medical record, please download the Medical Records Request form. Please fill it in completely and you either may bring it with you, mail or fax back to our office at 708-229-5193. Federal law requires you complete the authorization form before we can fulfill your request. A $25 payment will be due to begin processing the medical records request and may take one to two weeks to complete. 

Access Your Medical Record Form

 

 

Little Company of Mary Map and Lab Locations

Little Company of Mary Map of Satelite Locations.

Little Company of Mary Convenient Lab and Imaging Locations and Hours.

 

 

School & Sports Physical Forms

State of Illinois Certificate of Child Health Examination-School Physical
State of Illinois Pre-participation Examination Form-Sports Physical  

 

 

Power of Attorney

State of Illinois Statutory Short Form Power of Attorney for Health Care.

 

 

Do Not Resuscitate 

State of Illinois Department of Public Health Uniform Do-Not-Resuscitate (DNR) Advance Directive Form.

 

 

Vaccination Refusal Form

Vaccination Refusal Form from the American Academy of Pediatrics.

 

 

Certification for Plates or Parking Placard

State of Illinois Persons with Disabilities Certification for Parking Placard/License Plates.

 

 

Financial Policy

Please bring your insurance card to every visit.

 

For your convenience, we have answered a variety of commonly-asked financial policy questions below. If you need further information about any of these policies, please ask to speak with the Office Manager.

 

How May I Pay?

We accept payment by cash, check, VISA, Mastercard.

 

Which Insurance Plans Do You Contract With?

Medicare

Plus many more insurance plans

 

What Is My Financial Responsibility for Services?

Your financial responsibility depends on a variety of factors, explained in our Financial Policy.

 



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Support Groups

Breast Feeding Support Group

11:30AM - 12:30 PM


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2

Adult Wellness

Diabetes tool kit

9:00AM - 10:00 AM


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7

Nutrition Fitness & Weight Loss

Overeaters Anonymous

11:30AM - 12:30 PM

Aug 7, 2015

Little Company of Mary Hospital Receives American College of Cardiology Award for Cardiac Care

Jul 30, 2015

LCMH Bariatric Surgery Center Earns Comprehensive Center of Excellence Re-Accreditation

Jul 17, 2015

LCMH Named Outstanding Clinical Site by Rosalind Franklin University of Medicine and Science

 
 

I was recently admitted onto the 3rd floor after being rushed to the Emergency Room last week on Wednesday, O...

 
 
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