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 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



MAR

4

Support Groups

Breast Feeding Support Group

11:30AM - 12:30 PM


MAR

5

Adult Wellness

Women in Balance:Use your diet to prevent cancer

1:30PM - 2:30 PM


MAR

7

Family Birth Center Classes

Birthing Basics

10:00AM - 12:30 PM

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Feb 24, 2015

Record Breaking Attendance at This Year’s LCM’s Celebrate the Heart of Women Event

Feb 11, 2015

Little Company of Mary Offers Grief Support Program for Children and Adults in the Community

 
 

As a volunteer at Little Company of Mary Hospital and Health Care Centers, I work in the Ellyn Cronin Library, w...

 
 
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