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

31

Family Birth Center Classes

Infant-Child CPR

7:00PM - 9:00 PM


APR

1

Support Groups

Breast Feeding Support Group

11:30AM - 12:30 PM


APR

4

Family Birth Center Classes

Infant Massage

12:00PM - 2:00 PM

Mar 23, 2015

Little Company of Mary Hospital Named One of the Nation's 100 Top Hospitals by Truven Health Analyti

Mar 9, 2015

LCM Receives the 2015 Women’s Choice Award As America’s Best Breast Center for the Consecutive Year

Mar 2, 2015

Cancer is No Match for One Area Woman and her Healthcare Team

 
 

Dear Mr. Reilly and Sister Kathleen: Approximately one month ago, I suffered from an acute allergi...

 
 
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