Registration documents for clinic & hospital visits

Below are some of the documents you may need to acknowledge during your clinic or hospital visit. You’ll receive instructions from the team member who schedules, registers or checks you in about which ones apply for a given visit.

Documents for both clinic and hospital visits

Acknowledgment and Refusal of Interpretation Services Form

The Acknowledgment and Refusal of Interpretation Services Form outlines the language and auxiliary services that are available at no cost to you. This document also allows you to decline these services.

Guarantor Cell Phone Consent

The Guarantor Cell Phone Consent outlines our policies related to communications regarding collecting payment for services.

Financial Responsibility Agreement

The Financial Responsibility Agreement is used when your medical insurance coverage is unable to provide authorization or when you are considered out of network with Advocate Health Care.

Clinic documents

Ambulatory Consent to Treat, Payment and Notice of Privacy Practices

The Advocate Health Consent to Treat, Payment and Notice of Privacy Practices is your consent to treatment, release of health information necessary for your treatment, and consent for us to submit claims to your health insurance.

Related information

Care Everywhere Opt-Out

Care Everywhere is a functionality that allows us to share and receive your existing medical information with other health systems. The Care Everywhere Opt-Out form is completed if you would like to opt out of this service.

HIPAA Health Plan Restriction Request

This document allows you to request that we withhold providing personal health information to your insurance company for a given date of service or health care item. There are several provisions and restrictions related to this request that you should be sure to review.

Hospital Documents

No Surprise Billing Disclosure

This document explains the protection you now have against surprise bills, what balance billing is, and how to contact Advocate Health if you feel you have been wrongly billed.

Blue Cross Blue Shield Coordination of Benefits

The Blue Cross Blue Shield Coordination of Benefits form is used to collect other coverage plan information for your Blue Cross Blue Shield plan.

General Health Care Consent Form

The General Health Care Consent form allows us to provide treatment and diagnostic testing. It allows us to bill for services rendered. Please refer to the document for additional information.

Important Message From Medicare (IMM)

The Important Message from Medicare outlines your rights as a Medicare patient while admitted for inpatient care.

Note: if you have a Medicare Advantage plan, not traditional Medicare, and if you missed the deadline to request an appeal, please see the below information or locate the customer service number on your Medicare Advantage plan insurance card.

Medicare Advantage Coverage Plan

Phone Number

United Healthcare / AARP Medicare Complete

800-643-4845

Aetna Medicare PPO / POS / Value

833-570-6670

Aetna Medicare Advantage HMO

800-282-5366

Aetna Coventry / Aetna Medicare HMO

855-223-4807

Aetna Better Health

866-600-2139

Blue Shield Medicare Advantage HMO

877-774-8592

Cigna Healthspring True Choice PPO / Medicare Advantage / HMO

800-230-6138

Humana Medicare Advantage HMO / Community Select / Gold / Choice

800-457-4708

Humana Medicare and Medicaid

800-787-3311

Meridian Medicare and Medicaid

888-437-0606

Morecare Advantage HMO

844-480-8528

United Healthcare Solutions PPO

888-223-1092

United Healthcare Complete Assure PPO

877-842-3210

Wellcare Medicare Advantage HMO

855-538-0454

Other Medicare Advantage Plans not listed

See back of your insurance card

Important Message From Tricare

The Important Message from Tricare outlines your rights as a Tricare patient while admitted for inpatient care.

Medicare Outpatient Observation Notice (MOON)

The Medicare Outpatient Observation Notice outlines your Medicare coverage when you are considered as observation status in the hospital.

Notification of Observation Non-Medicare

The Notification of Observation Non-Medicare form outlines your coverage when you are considered as observation status in the hospital.

Medicare Outpatient Notice of Coinsurance

The Medicare Outpatient Notice of Coinsurance describes how your care will be billed using hospital-based billing practices.