Office Locations
Crystal Lake420 N. Route 31Crystal Lake, IL 60012 Phone: 815.356.5200 Fax: 815.356.5262 Office Hours |
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Scheduling your appointment
Your time is important and we respect that. With this in mind, patients are seen by appointment only. In an emergency, you will be seen promptly. We recommend scheduling appointments as far in advance as possible so we may better accommodate you. If you must cancel your appointment, please do so as early as possible to allow another patient to be seen. Failure to cancel an appointment at least 24 hours in advance may result in a $25 cancellation fee. We make every effort to see you at your appointed time. We greatly appreciate your understanding for any unforeseen delays that may result from emergencies.
Prior to your office visit please click on the appropriate form/s below and download. Completely fill out the form/s prior to your office visit with your physician. If you cannot access the forms you can click on the Adobe icon to download the software.
- HIPAA Privacy Notice
- Acknowledgment of Receipt of Notice of Privacy Practices
- Patient Registration Form
- Minor Patient’s Parent Information Form
- Review of Systems Form
- Statement of Financial Responsibility
- Spanish Patient Registration Form
- Spanish Minor Patient’s Parent Information Form
- MRI Patient Prescreening Questionnaire
Thank you for allowing us to be a part of your orthopaedic care.
Self pay patients
Payment is due at the time service is rendered. For your convenience, we accept cash, check, money orders, Discover, Visa, or MasterCard. We do understand that unusual circumstances may arise and that payment in full at the time of service may not always be possible. To meet your needs, a representative from our financial department is available to discuss possible payment options.
Contracted PPO
Co-pays are required whenever seen by a physician and are due at the time of service.
Contracted HMO/EPO/POS
Most of these plans require a referral from your primary care physician and also mandate that you have the referral at the time of the appointment. Without your referral, you will be responsible for all charges at the time of service. If you have your referral with you or your plan does not require a referral at all, your designated co-pay is your only responsibility at the time of service.
Indemnity insurance/Out of network plans
As a courtesy, we will submit your claim to your insurance carrier for you, provided that you make available correct insurance information. We require both the deductible and 20% of the billed charges at the time services are rendered.
Workers’ compensation
At the time of your appointment, we require employer’s verification that injuries are work related, as well as all necessary billing information. These two conditions must be met in order to file a claim with any workers’ compensation carrier. Please remember that it is ultimately your financial responsibility for all services.
Medicare
Our practice accepts Medicare assignment. Your financial responsibility will include 20% of the Medicare allowable, annual deductible, and non-covered items (i.e. cast shoes, slings, etc.). We will submit all portions of your financial responsibility to your secondary insurance carrier, as long as you provide us with appropriate secondary insurance information.
Motor vehicle accidents
For any motor vehicle accidents, automobile insurance must be submitted as primary. Our office submits to the med-pay portion of the auto policy. Once the auto med-pay is exhausted, we will gladly submit to your health insurance as a secondary carrier, as long as you provide us with all necessary billing information.
It is your responsibility to follow the specific instructions of your particular insurance plan. Furthermore, you are responsible for payment of your account, not your insurance company. In cases of divorce, the parent who brings the child in for treatment will be responsible for payment and collecting from all other parties. A representative from our financial department is available to assist you.