Before Your Visit (forms, etc.)
To help us make the most of your visit, please come to the office prepared with the following:
- Insurance card(s) and an Identification Card (i.e. Driver’s License)
- Proper referral or authorization from your insurance company (if required)
- Valid Referrals for patients with HMO insurances
- List of Medications you are currently taking
- Be prepared to give a Urine Sample when you arrive to the appointment
- Related lab reports, x-rays, consults or reports and previous records
- Print and Complete the New Patient forms: Medical History Form, HIPAA, and Patient Registration Form
- AUA Symptom Score form
Also, we ask that you please arrive at our office 20 minutes prior to your appointment time.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Medical Records Release Form
Please use our Medical Records Release Form to obtain a copy of your medical records or to have your medical records sent to another physician.
Please fax completed requests to (815) 741-3263 attn: Emma.
Medical records sent directly to another physician or medical facility will be given free of charge as a professional courtesy. Other recipients of the records, including the patient, will be subject to our release fees.