Patient Information

What to Bring to the Appointment

• Insurance card
• Physician referral forms if required by insurance
• A list of current prescription or over-the-counter medications, including dose and frequency
• Pertinent information about your medical and surgical history
• Any recent x-rays or appropriate records you may have

Patient Forms

The following is a link to our downloadable patient forms. Please print and complete them before your appointment. [printable page troubleshooting]

• Patient Forms

HIPAA/ Privacy Forms

• Notice of Privacy Practices
• Standard Authorization of Use and Disclosure of Protected Health Information
• Communication Waiver
• Request for Accounting of Protected Health Information Disclosures
• Request for Confidential Communication of Protected Health Information
• Revocation of Authorization for Use and Disclosure of Protected Health Information
• Business Associate Agreement

Payment and Insurance Information

Ronald D. Lee, MD, FACS, of Northwest Suburban Urologists, LTD, is a provider for Medicare and most major insurance plans. We provide insurance billing. Anything not covered by insurance will be your responsibility.

We request payment at the time of your appointment for services that are not covered by insurance. Your insurance company may also require you to pay a co-payment at the time of your appointment. When necessary, our staff will work closely with patients who require a payment plan.

If you have any questions regarding which insurance plans we accept or any patient billing concerns, please call us at the phone number below. Questions regarding your coverage and benefits should be directed to your employer or insurance company.