Before you stop in to see us for your first appointment, we ask that you take a moment to print and fill out the forms below to help expedite your visit:
In addition, please be prepared to provide the following items at the time of your visit:
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Identification: Valid Driver’s License of State ID
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Proof of Insurance: Current Insurance Card
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Referral: If required by your HMO, please bring your doctor’s referral
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Test Results: If you took any labs, x-rays or tests prior to your visit, please provide your results
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Medications: If unable to fit all on the medical history list, please bring a full listing of medications
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Allergies: Be prepared to provide a listing of any allergies you may have to specific medications
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Medical Records: Please provide any previous medical records relating to your current condition
Please expect a call from our office prior to your scheduled appointment to remind you of the date and time. We reserve the right to charge a fee of $50.00 for appointments that are cancelled, broken, or missed without 24 hours advance notice.
For your convenience, our office accepts cash, check, Visa, Mastercard & Discover. Payment is due at the time of service in the following circumstances:
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If you are not covered by an Insurance Policy
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If your Insurance Policy requires a co-pay
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If you are covered by Medicare and your annual deductible has not been met
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You have met your annual Medicare deductible but do not have a secondary insurance
(20% will be due)
Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement: Discrimination is Against the Law
This office at 1703 Polaris Circle Ottawa, Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Our office does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Our office: Provides free aids and services to people with disabilities to communicate effectively with us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: ○ Qualified interpreters ○ Information written in other languages If you need these services, contact Civil Rights Coordinator. If you believe that the has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Jeffrey Crowhurst DPM 1703 Polaris Circle Ottawa, Illinois Phone: 815-434-1900 Email: crowfoot@sbcglobal.net. Fax: 815-434-0933. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Jeffrey Crowhurst is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.