Forms and Policies

The Chicago Pediatric Clinic is an independent, privately owned and operated pediatrics group with its main office situated in Lakeview.

On this page we provide information about our general office policies and some links for forms that you can print out and complete, prior to your scheduled appointment, to save time.

Appointments
Telephone calls
Laboratory
Referrals
Privacy Practices
Financial Policy
Camp/school/sport physical forms
Prescription refills

Print out the forms below and bring them with you to your child’s appointment.

Appointments: We ask that you arrive at your appointment time or earlier if needed, to update any insurance information. Each patient is scheduled and not double-booked. We do not accept walk-ins.

If you arrive late or past 20 minutes after your scheduled appointment time, you may have to be rescheduled for a later date or your appointment time may be shortened.

We understand that sometimes emergencies may arise. If you are unable to make your appointment time or need to reschedule, please call us as soon as possible, so we may give this opening to a child who is ill. However, if you do not call and do not come to the appointment, we may charge you a $30.00 cancellation fee. We respect your time and expect the same from our parents. The no-show charge will be waived if you cancel the appointment with more than 24 business hours notice prior to the scheduled appointment time. Please be advised that your insurance will not cover this no-show fee.

In order to prevent the spread of illnesses, we recommend that only the patient be brought to the clinic with the parent(s) or guardian. Parents will be responsible for their children’s behavior and conduct while in the clinic.

Telephone Calls: During working hours, all non-urgent telephone calls will be returned at the end of the office day or between patient visits. An urgent call will be treated with great seriousness and every attempt will be made to return the call as soon as possible.

After hours and weekend phone calls will be answered promptly by the pediatrician on-call. Please follow the instructions given on the clinic answering service.

Please be aware that there may be a charge for any after hour/weekend calls.

If for some reason you do not receive a return call after two calls, assume that the doctor’s telephone system is not functioning properly and take your child to the nearest hospital.

Laboratory: Please provide the medical receptionist, assistant or doctor with the name of the laboratory to where we may send any of your child’s blood work or tests. Insurance carriers may request that blood work/tests be sent to a particular laboratory. We send all specimens to Quest Laboratories unless you indicate otherwise. You are responsible for notifying the clinic staff if tests must be sent to a different laboratory, such as ACL or LabCorp labs. We will not be responsible for any bill if you have a test at the wrong laboratory location and/or unauthorized service.

Referrals: If you require a referral for a service at another facility, please allow at least one week for our medical assistants to complete the necessary paperwork and/or input the information into the computer. It may take several days for us to get an approval from your insurance for the service. Please do not go to see a specialist unless you have your referral in hand. If the parent/guardian chooses to take the patient to undergo any service without a valid referral, the parent/guardian is financially responsible for the full charges.

Camp/School/Sport Forms, other: School, daycare, camp and other forms such as FMLA forms take time to review and complete. Please allow at least 2 weeks to provide the requested information. These forms incur a $10.00 fee. If you require these forms to be filled out within 48 hours, there will be an additional $10.00 fee. Forms will be completed for patients who have been evaluated in the clinic within the past 12 months. Forms will be held at the clinic for parents to pick up. Because of the Health Insurance Portability and Accountability Act (HIPPA) regulations, forms will be released to parents/guardians only. We are prohibited from faxing or mailing medical information to non-medical facilities. Forms are completed for those patients whose accounts are in good standing.

Prescription Refills: We ask for at least 24 hours notice for prescription refills to make sure that we can review your child’s chart and assure we are offering the best care for any ongoing issues. Please contact your pharmacy and request that they fax your doctor a written request for the refill. Our fax telephone number is 773-477-1510. There is no fee for prescription refills.