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Insurance card: If you do not have insurance you will be
directly responsible for payment of office visit charges.
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HMO and
POS patients only: We will also need a referral from your
primary care physician. You can either bring the referral with
you, or you or your physician can fax it directly to our office
(847) 723-9050. Please mark it to the attention of Pediatric GI.
If you do not have a referral your office visit will be
rescheduled to a later date so that you can obtain a referral.
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Co-pay:
If your insurance coverage requires a co-payment (usually
$5-$30), please note payment is
expected at time of service. We do accept cash, check and all
major credit cards.
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Results
of prior testing: (e.g. blood work, stool testing, GI related
x-rays). We need all test results even if they were negative. A
release of information for our office is attached. We do prefer
records to be faxed, however if there is a lot or if the
facility does not fax the address is also specified.
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If your
child is being seen for failure to thrive/poor weight gain,
obtain the updated growth chart from your primary care
physician.
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If you
child has had an Upper GI or any other type of other X-ray we
ask that you bring copies of the films with you at the time of
you appointment.
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The
review of systems sheet. Please fill out and bring it with you
to your visit. If you have any questions or are unsure leave the
question blank and ask us at the time of your visit.
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If you
are a new patient the
demographic
sheet and
privacy statement. Please fill out, sign and date, and bring
it with you to your visit. |