630-690-7115

Patient Forms

forms with glasses and a pen

PATIENT FORMS

Please complete the following forms and bring them and the other items listed to the appointment:

  • HIPAA- Acknowledgement of Receipt form (HIPAA document available at our facility)
  • Medicare/Insurance Information Sheet
  • Your Medicare Card and/or current Insurance information, if Medicare please complete the attached “Advanced Beneficiary Notification (ABN)” form and bring with you to your appointment:  selecting option 1 on the form allows us to submit to Medicare, and if denied, allows you to contest the Medicare ruling.
  • A current Photo ID
  • Medication list from your primary physician OR Please compete the attached: “Spectrios Institute Patient Medications List” form for any medication you are taking (prescription and over the counter).

DOWNLOAD THE FORMS HERE

If you have any questions, please feel free to contact Spectrios Patient Services Department
(630-690-7115 ext 123).

For Health Reasons: It is important if you have a cold, the flu or have been exposed to a contagious disease, that you reschedule your appointment. This is to protect you, other patients, visitors and our staff. Thank you for your understanding.