Itemized Statement Requests
Please fill out the form below to request an itemized statement:
Name
*
First Name
Last Name
Email
example@example.com
Patient's Name (if different than the requester)
First Name
Last Name
Relationship to Patient
(Ex. Parent or Guardian)
Date of Birth
*
-
Month
-
Day
Year
Date
Location Visited
Archer Heights, Chicago, IL
Aurora, IL
Belmont Cragin, Chicago, IL
Blue Island, IL
Bolingbrook, IL
Bourbonnais, IL
Burbank, IL
Calumet Park, IL
Carol Stream, IL
Cedar Lake, IN
Cicero, IL
Chicago Ridge, IL
Crown Point on 109th & Broadway, IN
Crown Point on Burr & 30, IN
Dyer, IN
Elmhurst on Butterfield, IL
Elmhurst on York Street, IL
Evergreen Park, IL
Gage Park, Chicago, IL
Garfield Ridge, Chicago, IL
Griffith, IN
Griffith next to Walgreens, IN
Hammond on 5th Avenue, IN
Hammond on Sibley, IN
Hobart, IN
Hyde Park, IL
Lakeview, Chicago, IL
Logan Square, Chicago, IL
Lombard, IL
Matteson, IL
Mayfair, Chicago, IL
Melrose Park, IL
Merrillville, IN
Merrillville next to Walgreens, IN
Michigan City, IN
Mt. Greenwood, Chicago, IL
Munster, IN
Norridge, IL
Northbrook, IL
Oak Forest, IL
Portage, IN
Portage next to Walgreens, IN
Portage Park, Chicago, IL
Richton Park, IL
River Forest, IL
River North, Chicago, IL
Rogers Park, Chicago, IL
Roscoe Village, Chicago, IL
Schererville, IN
Skokie, IL
Tinley Park on Harlem, IL
Tinley Park on LaGrange, IL
West Loop, Chicago, IL
Westmont, IL
Wheaton, IL
Wicker Park, Chicago, IL
Willowbrook, IL
Date of Requested Visit
-
Month
-
Day
Year
Date
Questions or Comments?
By clicking the checkbox provided, you acknowledge and agree that you are either the legal guardian of the child for whom you are requesting itemized statements, or you are the individual directly requesting the statements for yourself. This confirmation affirms your responsibility and authorization to access and receive the requested itemized statements on behalf of the specified child or yourself. Please proceed with the understanding that any misuse or unauthorized access may result in legal consequences. If you do not meet these criteria or do not agree with the terms, refrain from clicking the checkbox and contact the appropriate party for further assistance.
*
I have read the above disclaimer and fully understand its contents.
Submit
Should be Empty: