Office Locations
420 N. IL Route 31 |
10350 Haligus, Suite 120 |
Phone: 815.356.5200 Office Hours |
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
- Records Release Form
Thank you for allowing us to be a part of your orthopaedic care.
The following information will help you understand your financial responsibilities…
- You will receive an invoice at each visit which denotes fees and/or payments.
- Payment in full is required at time of service; this includes any outstanding personal balances at time of service.
- MCO does not have access to your insurance policies specific coverage, benefits, limitations, provisions and/or exclusions. For this information you may contact your insurance company directly or your employer’s human resource department. Your insurance company will provide you with an explanation or summary of benefits after each visit which itemizes your financial responsibility to MCO. Please remit payment to MCO within 10 days of receipt of the explanation or summary of benefits.
- MCO will issue one statement. If it becomes necessary to issue additional statements due to nonpayment a thirty-five dollar rebilling fee will be assessed to your account.
- In cases of divorce or separation, the party responsible for the account is the parent authorizing treatment of the child.
- A representative from our financial department is always available to assist you with questions or concerns.
Contracted PPO’s
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 a 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; 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 claims 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.
Worker’s 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 if your employer eventually denies your claim.
Medicare
Our practice accepts Medicare assignment. Your financial responsibility will include 20% of the Medicare allowable, annual deductible, and non-covered charges. 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.
Self Pay
Payment is due at the time service is rendered. For you convenience, we accept cash, checks, money orders, Visa, MasterCard or Discover.