Forms and Policies

Forms and Policies

Medical Forms and Policies

Your Personal Information

We value your privacy and follow all HIPAA guidelines and regulations.

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 appointments by clicking on the forms below.

Patient Registration Form

 

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 below.

Financial Policy

 

Access your Medical Record

To access your medical record, please download the Medical Records Request form. Please fill it in completely and bring it with you. 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



JUL

30

Support Groups

Breast Feeding Support Group

11:30AM - 12:30 PM


JUL

30

Family Birth Center Classes

Breast Feeding Support Group

11:30AM - 12:30 PM


JUL

30

Support Groups

Breast Feeding Evening Support Group

7:00PM - 8:00 PM

May 22, 2014

LCMH Palliative Care Program Offers Chronically Ill Patients an Improved Quality of Life

May 20, 2014

LCMH Excels in Patient Safety-Awarded an “A” in Spring 2014 Hospital Safety

Apr 23, 2014

Chicago Family Physician Advocates for Change in Health Care System

 
 

Dear Mr. Reilly, I was a patient at Little Company of Mary Hospital on May 20, 2010, for a lung bi...

 
 
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