Patient Forms

New patient registration packet

For patients who are new to Primary Care Services. Includes patient and insurance information and a health history section, so there is no separate medical history form to complete.

Medication list

A one-page template to record every medicine you take — prescriptions, over-the-counter products, vitamins, and supplements — with the dose and how often you take it.

Referral request form

Ask your Primary Care Services provider to consider a referral to a specialist or an outpatient service such as physical therapy. Your provider reviews the request and decides whether a referral is appropriate.

Notice of Privacy Practices

Explains how Primary Care Services may use and share your health information and your rights over that information. This is for you to keep — there is nothing to fill out.

Authorization for release of health information

Use this form to allow Primary Care Services to share your medical information with a person or organization you name — for example a family member, an attorney, or another clinic. This is also the form to use to request your own records (see “Medical records” below).

Consent for treatment

General consent for medical treatment and examinations. It also covers assignment of insurance benefits and the practice’s appointment cancellation and no-show policy.

Billing & insurance — what to bring

There is no separate insurance form to download. Your insurance details are collected on the new patient packet, and assignment of benefits is part of the Consent for Treatment.

1. 1Bring your current insurance card (and a photo ID) to every visit and give it to the front desk.
2. 2Bring your copay. Copays are due at the time of service.
3. 3Tell us right away if your insurance changes so claims go to the right plan.

Request your medical records

You have the right to a copy of your medical record. Under HIPAA and Illinois law the fee a provider may charge is limited, and records must be provided within the timeframe the law allows.

1. 1Use the Authorization for release of health information form above.
2. 2In Section 1, list your information. In the “release to” section, name yourself (or the provider or person who should receive the records).
3. 3Be specific about what you need — for example “office visit notes and lab results from the last two years.”

Illinois advance directive forms

Advance directives let you state your wishes for medical care and name someone to speak for you if you cannot. Illinois publishes the official statutory forms — use these current versions rather than a copy. Give a completed copy to Primary Care Services so it can be added to your record, and to the person you name.

• Power of Attorney for Health Care (English)
• Poder para Atención Médica (Español)
• Living Will Declaration (English)
• Declaración de Testamento Vital (Español)
• Declaration for Mental Health Treatment (English)
• Practitioner Orders for Life-Sustaining Treatment (POLST)

Sign up for the patient portal

Primary Care Services uses the LiveWell with Advocate Health portal (MyChart) for online access to your records, test results, and secure messaging. There is no paper form — you enroll online.

1. 1Ask the front desk for an activation code at your next visit, or start sign-up online.
2. 2Go to the portal and choose “Sign Up Now,” then follow the steps to verify your identity.
3. 3Once you are in, you can view visit summaries and results, message your care team, and request appointments.