Forms and Policies

Forms and Policies

LCM Medical Forms and Policies


Patient Registration Information

We are excited that you have chosen Little Company of Mary Medical Group and appreciate the trust you have placed in us. To ensure the highest quality care, we will need certain information from you and you will want information about us. Please take a few minutes to review the documents below by clicking on the links provided. Please complete and bring in the Patient Registration Form to your office visit.


To better understand your financial responsibility, please review our Financial Policy Statement. Always bring a current insurance or enrollment card along with your ID, to each office visit. Your Co-pays are collected at Check In. We accept cash, personal checks, Visa, Mastercard and Discover. We accept a variety of insurance plans.


Little Company of Mary Hospital treats all patients with dignity and respect, regardless of their financial situation. We have Financial Counselors available to answer questions about your medical bills. Call 773.863.7550 to learn more information.


Welcome Letter

Patient Registration Form

Authorization for Medical Treatment of a Minor

Authorization to Share and Recieve Medical Information

Notice of Privacy Practice and Acknowledgement (English)

Notice of Privacy Practice and Acknowledgement (Spanish)

Patient Secure Messaging

Financial Policy Statement



Medical Record Release of Information 

To access your medical record, please download the Medical Record Request Form. Please fill in completely and you may either bring it in with you, mail or fax back to our office at 773.863.7506. Federal law requires you to complete the authorization form before we can fulfill your request. Processing medical records requests may take 7-14 business days to complete.

Access Your Medical Record Form



School & Sports Physical Forms

State of Illinois Certificate of Child Health Examination-School Physical
State of Illinois Pre-participation Examination Form-Sports Physical  



Vaccination Information


Education & Resources

Centers for Disease Control and Prevention- Vaccines for Your Children: Protect Your Child at Every Age.

Centers for Disease Control and Prevention- 2016 Recommended Immunizations for Children from Birth Through 6 Years Old.

Centers for Disease Control and Prevention-2016 Recommended Immunizations for Children 7-18 Years Old.


Consent and Screening Checklist Form

Immunization Welcome Letter

Screening Checklist for Adult

Screening Checklist for Child

Refusal to Vaccinate Consent Form

Illinois Certification of Religious Exemption to Required Immunization and/or Examinations Form



Questionnaire for Medicare Annual Wellness Exam

*Please print and fill out this questionnaire and bring it to with you to your next wellness appointment!



Do Not Resuscitate 

State of Illinois Department of Public Health Uniform Do-Not-Resuscitate (DNR) Advance Directive Form.



Power of Attorney

State of Illinois Statutory Short Form Power of Attorney for Health Care.



Certification for Plates or Parking Placard

State of Illinois Persons with Disabilities Certification for Parking Placard/License Plates.



Little Company of Mary Map and Lab Locations

Little Company of Mary Map of Satelite Locations.

Little Company of Mary Convenient Lab and Imaging Locations and Hours.



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