office policy form – aedoctors

Tina Bansal, MD
800 E Woodfield Rd, Ste 113. Schaumburg, IL 60173
Phone: 847-686-6866 Fax: 847-706-9891

Patient Name: Date of Birth:

Welcome to our practice! We take great pride in your health and it is our privilege to partner with you in your care. Here are a few things you need to know that will help us give you the best possible service:

About the doctor... Dr. Bansal is an Endocrinologist, a physician who specializes in the care of hormone problems, and asks therefore that you maintain your relationship with your primary care physician.A primary care physician may be able to see you on short notice if you have a cold, fever or need pain evaluated. If you do not have a primary care physician, we’d be happy to recommend one. Our Nurse Practitioners, Lisa Curry and Kimberly Nicholson, specialize in endocrinology and are more than capable and happy to help you with your endocrinological needs.
About prescriptions... Please be sure you are keeping track of your prescriptions. We take great pride in filling prescriptions in a timely manner. We never want to see a patient run out of medications.Please allow up to 48 hours for your prescription to be filled. That is, always keep at least two days of extra medication to be sure you will not be running out. To get your prescription filled, please call your pharmacy and ask them to fax us over a refill request.Medications list information... It helps to keep an updated medications list in your wallet that includes names, dosing and frequency of your medications. Please be sure to bring your updated medications list to every visit as the staff will be asking you to update your list at the time of your appointment.
Blood sugar logs... If you are diabetic or have another chronic medical condition, consider getting a Medic-Alert bracelet. For diabetics, keeping a written log of your sugars is necessary for the Provider to instruct you regarding your medications. Please be sure to bring all updated blood sugar logs to each appointment. If you have a meter, insulin pump or other diabetic device please bring this as well.
About scheduling appointments... We are typically booked 4-6 weeks out for routine follow up appointments. Therefore, it is best to schedule follow ups at the time of each visit. Please note: APPOINTMENTS MUST BE CANCELLED MORE THAN 24 HOURS IN ADVANCE (MONDAY APPOINTMENTS MUST BE CANCELLED NO LATER THAN 5:00PM THE FRIDAY BEFORE) OR A FEE WILL BE CHARGED TO YOU.
About appointment frequency... Most diabetic patients are requested to follow up with their endocrinologists once every three months unless other accommodations have been made. For patients with medical problems other than diabetes, you may need to be seen much more frequently in the short term and then as little as once yearly. Your care may even be turned back over to your primary care physician. If you have cancelled, delayed or not come to


appointments as recommended, the doctor may decide not to fill your prescriptions and, in some cases, it may be necessary to terminate your care. Our Providers firmly believes it is not good medical practice to fill medications for patients who have not been evaluated at a reasonable frequency.

About test results... Unless the Provider tells you differently, all test results will be discussed with you at your next scheduled visit. If you are asked to call for test results please allow up to 48 hours for a return call from our office.

Financial Responsibility Agreement: (please initial on the provided line)

I agree that I am ultimately responsible for payment for services provided to me. This payment of services may include insurance copayment, deductibles, coinsurance and non-covered services.

I agree and authorize Advanced Endocrinology to release any information necessary to facilitate payment of claims.

All self-pay patients are required to pay in full at the time of services rendered.

Again, we look forward to caring for you, and are happy that you have chosen to allow us to participate in your medical care.
The Staff of Advanced Endocrinology

Patient Signature: