Home Your First Visit

Your First Visit

Provided below are various forms that require completion prior to your visit. Click on the appropriate form to download. Should you not be able to access the form, please click on the Adobe Box. This will allow you to download the free Adobe Software providing access to the forms.

• Adult Registration Form
• Pediatric Registration Form
• Adult Pre-Evaluation Form
• Pediatric Pre-Evaluation Form
• Medication List
• Disclosure Agreement Part I
• Consent Form Part I
• Privacy Notice Part I (for your information, no action is required)
  
• Workers’ Compensation Form

Forms may be faxed in advance of your appointment, to the office location of your visit.

If you cannot access the forms you can click on the icon to download the software.

FOR EVERY VISIT, PLEASE BRING:

• Current Insurance Card
• Driver’s License or State Identification

Test Results:

• X-Rays (CD provided by facility and/or films)
• MRIs (CD provided by facility and/or films)
• CT Scans (CD provided by facility and/or films)
• Ultrasound
• Labs (copy of report)

Medications:

• Update any changes in current medications

Paying for your visit:

• At the time of service, you are responsible for your co-payment, deductible, and any service or products that are not covered under your health insurance plan We accept cash, checks and all major credit cards.
• Patients without health insurance will be responsible for their bill at the time of service.
• Should your insurance plan require a referral, you must bring it at the time of your visit or you will need to pay on the day services are rendered.
• It is your responsibility to know and understand your health insurance plan benefits.
• As a convenience to you, our Accounts Receivable Department will submit your insurance claim and you will be responsible for any patient balance. Please contact this department at 847.298.7024 with any questions.
• Should you have a work related injury, please come to the visit with your claim number, contact person’s name, telephone number and claim submission address.
• Motor Vehicle Accidents will be billed to the auto insurance carrier. Please come to the visit with proof of authorization, claim number, agent’s name, telephone number, policy number and claim submission address.
• Inform our Accounts Receivable Department of any changes to your information 847.298.7024.