Medical Forms and Policies
Your Personal Information
We value your privacy by following all HIPAA guidelines and regulations.
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.
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 below.
Access your Medical Record
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.