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