New Patient Information and Forms
For your convenience, you may complete new patient forms in advance. Please select and print from the options below, fill them out completely and bring them with you to your appointment.
If you are not able to complete the forms before your visit, please allow at least 30 minutes for completion in the office before you see the doctor.
- New Patient & Other Forms Overview
- Authorization for Release of Confidential Medical Records (English)
- Medical History (English)
- Medical Record Release Form – MacNeal Hospital
- New Patient Questionnaire – Pediatrics (English)
- Registration Form (English)
- HIPAA Notice of Privacy Practices Acknowledgement
- Financial Policy (English)
- Authorization for Release of Confidential Medical Records (Spanish)
- Medical History (Spanish)
- New Patient Questionnaire – Pediatrics (Spanish)
- Financial Policy (Spanish)
- Registration Form (Spanish)
- Authorization for Release of Confidential Medical Records (Polish)
- Authorization for Release of Confidential Medical Records-Minors (Polish)
- Registration Form (Polish)
- Financial Policy (Polish)
- Medical History (Polish)
Please bring all medications you are currently taking to your appointment.
Personal Identification Needed
Be sure to have your valid driver license and insurance card(s) with you.
Due to recent changes in healthcare plans, some patients have questions regarding patient and insurance responsibility for services rendered. Our rates are representative of the usual and customary charges for our area. Please review our payment policy information below. You will be provided with a copy of this information to read and sign at your office visit. Please let us know if you have any questions or concerns.
We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, present your current card at your office visit so that we may verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
Co-payments and deductibles
All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment and/or deductible at each visit.
Payments can be made in the form of cash, personal check or credit card. We accept MasterCard, Visa, Discover and American Express.
If your insurance changes, please notify us before or on your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay within 30 days, you will be responsible for the balance.