Printable Patient Forms
Adult Patient Packet
Authorization for Release of Confidential Health Information
Medical Care Request and Authorizaton
Financial Assistance Program
Worried About Your Ability to Pay?
At HSHS Medical Group, we understand that the cost of health care can be an unexpected burden. That’s why we are pleased to offer a Financial Assistance Program, which provides discounted medical care to patients who qualify.
Whether you’re uninsured or underinsured, you can apply for financial assistance. Applications are also available at the front desk, as well as online at Financial Assistance Application.
Eligibility is based, in part, on your income and the size of your family. You will be asked to provide several documents with your application.
Please be prepared to include the following documents with your Financial Assistance Program application:
- Past three months’ bank statements for all accounts.
- Latest Federal Income Tax Return, including W-2 Earnings Statements.
- Payroll check stubs, bank statements, or other documentation of monthly income, sources reflecting income, of all responsible parties for at least the three months prior to application.
- If applicable, please provide a statement of monthly benefit from Social Security or other retirement or disability benefits.
- Copies of rent or mortgage payments and utility bills.
- If applicable, please provide Medicaid/Medicare Approval/Denial Letter, Denial of Unemployment or Workers’ Compensation Benefits.
- Valid state issued identification, a utility bill received within the last 60 days, a lease agreement, vehicle registration card, or mail addressed to patient from a local State or Federal Government entity.
- Copies of any other supporting documentation you feel should be included.
We will send you a letter once your application has been reviewed and a determination is made.
For more information on Financial Assistance, please call Patient Financial Services at 1-877-636-2261 or email PFS@hshs.org.
Financial Assistance Program resources:
HSHS Medical Group Insurance Plans
Information on accepted insurance plans can be found here. Some insurance carriers include county and/or plan restrictions. If you have any questions, please contact Patient Financial Services at 877 636-2261.
Uninsured Americans are now able to use new “Health Insurance Marketplaces” to find insurance that is affordable and meets their unique health care needs.
For Illinois Residents
Sign up by visiting www.GetCoveredIllinois.gov or calling 1-866-311-1119.
For Wisconsin Residents
Sign up by visiting www.healthcare.gov or calling 1-800-318-2596.
The Insurance Marketplaces will allow people to compare prices and shop for health insurance—online or by phone. The information about each insurance plan will be provided in easy to-understand language. All insurance plans will have to show the costs and what is covered in simple language with no fine print.
Help is available to pay for insurance
Financial assistance will be available to help many Americans afford quality health coverage.
For Illinois Residents
The amount of financial assistance a consumer qualifies for is based on their income and family size. For example, an individual making less than $15,900, and a family of four earning less than $32,500, will qualify for free or low-cost Medicaid coverage. An individual making between $15,900 and $47,000, and a family of four earning between $32,500 and $94,000 will qualify on a sliding scale for financial assistance to help buy private insurance in the Marketplaces. For those who qualify, the average annual tax credit for an individual will be $5,290.
For Wisconsin Residents
The amount of financial assistance a consumer qualifies for is based on their income and family size. For example, an individual making less than $11,450, and a family of four earning less than $23,550, will qualify for free or low-cost Medicaid coverage. An individual making between $11,450 and $47,000, and a family of four earning between $23,550 and $94,000 will qualify on a sliding scale for financial assistance to help buy private insurance in the Marketplaces. For those who qualify, the average annual tax credit for an individual will be $5,290.
To determine how much assistance you may qualify for, here is a subsidy calculator from Kaiser Family Foundation.
Please click here for more facts about the Health Insurance Marketplace.
Why One Health Visit May Result in Two Charges
In an effort to keep our patients informed we want to make you aware of why one visit may result in two charges.
Patients have two primary reasons for visiting their provider - a general visit to maintain health (preventative/wellness care), or a specific health concern that needs addressed, such as an illness or injury (problem-related care).
For the convenience of our patients, our providers are happy to care for these two types of needs in one visit as time allows. However, insurance often views these as two separate items. You may have additional co-pay and/or your bill may show two charges: one for preventative/wellness care and one for problem-related care.
What's the difference?
- Treatment for a new health problem
- Follow up care for exisiting illness/condition such as diabetes, high blood pressure, high cholesterol, joint pain, sore throat, etc.
- Evaluate & maintain your general health
- Regular screening tests
- Evaluate risk of future problems
- Catch a problem early
- Review history of new or exisiting problem
- Exam and/or discussion concerning problem
- Lab or other test related to new existing problem
- Prescription for new or existing problems
- Review health history
- Discussion with provider regarding preventative measures
- Screening Tests:
- Cholesterol test
- Prostate Screening
- Pap test
If you have any additional questions, please contact your insurance company regarding coverage and/or benefits.
Chart My Health
View Your Health Records From Your Computer or Mobile Device
HSHS Medical Group now offers our patients one of the newest and easiest tools for health care management. Chart My Health is a FREE online personal health record that you can access securely from your home computer, laptop or mobile device. Chart My Health gives you the ability to communicate directly with your doctors, view your medical records, and much more. Take this opportunity to become an active participant in your own health and wellness. If you have already registered, LOGIN NOW >
Download the Follow My Health™ App for Android or iPhone to view your Chart My Health records on your mobile device.
Chart My Health Allows Patients To:
- Retrieve updated health information electronically anywhere, anytime via personal computer, laptop, mobile device or smart phone
- Submit appointment requests and receive reminders of upcoming appointments
- Request prescription refills
- View lab results
- Communicate securely with your doctor's office
- View allergies, vaccinations and lab results
How to Sign Up
Just stop in at any HSHS Medical Group location to sign up. You will need to have a current email address. Ask any of our patient registration staff to sign you up for Chart My Health! After signing up, you will receive an email invitation with a link to activate your account and create an authentication ID.
To complete this online process, you will be required to enter an “Invitation Code,” which is your 4 digit birth year.
Contact the Chart My Health toll-free support line at 1-855-325-4747 or by email at email@example.com.
NOTE: Chart My Health/FollowMyHealth™ Universal Health Record is best viewed in our supported browsers (Internet Explorer 8 and higher and modern versions of Firefox, Chrome, and Safari).
Is Medicare Advantage the right choice for you?
With enhanced benefits, Medicare Advantage allows you to customize a program to fit your needs. Visit our Medicare Advantage page for more information.
Any refund of credit balances of less than $5.00 must be requested by calling (217) 528-0414. If you do not wish your refund to be in the form of a prepaid debit card, please request that a check be issued.