Patient Forms
To get started, please download the patient registration form below in your preferred language. For parents/guardians of those under 18 years old, please also fill out the matching consent form for treatment. In addition to your completed form(s), bring the items below to your appointment.
Photo identification
Insurance card (if you have insurance)
If you do not have insurance, that’s ok, we’ll help you enroll or provide services without insurance
A list of medications you are currently taking
Immunization records
Discharge papers if you were recently admitted to a hospital
To make an appointment, please call 312-633-5841.
24-Hour Care
Did you know that care is available 24/7 through our after hours care resource? Be sure to call 312-633-5841.
Translation Services
Translation services are available upon request at all sites.
Do you currently have Medicaid?
Did you know that individuals with Medicaid are required to redetermine (or renew) their eligibility every year?
Redetermination was placed on hold during the COVID-19 public health emergency, but it's now necessary.
Click here to update your home address on the Medicaid website.
Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.