Forms and Checklist

For Our Patients

CORE Orthopedics & Sports Medicine has four well respected physicians. Athletic injuries and on-the-job accidents causing minor or severe injury are treated expertly at CORE in the office or in a hospital. Our physicians review all possible non-surgical treatment options with the patient and work closely with physical therapists and trainers in-house to get the athletic back on the playing field or the worker back to work. If surgical intervention is needed then the latest techniques and facilities are available at four hospitals in the western suburbs of Chicago.

Patient Checklist

Please be familiar with this checklist before your office visit.

What To Wear

Patients having an examination of the Hips or Knees:
Please bring or wear shorts (without metal) for X-rays and examination.

Patients having an examination of the Shoulder or Back:
Please wear a tank top under shirt.

What To Bring

1. If you have had an X-ray or MRI, please bring the CD or films. This is very important! X-rays taken at Alexian Brothers, St. Alexius or Good Shephard can be viewed online, but studies taken elsewhere need to be brought in at time of appointment in order to prevent rescheduling of appointments.
2. Photo identification
3. Insurance Card
4. Co-payment
5. Any patient less than 18 years of age must bring an adult who is older than 18 years of age and is either a legal guardian or a letter by the legal guardian authorizing treatment and also a copy of the parent’s driver license.
6. Please bring your medication and past medical history list with you to your next appointment.

Patient Forms

Please fill out the following two forms before your appointment.

1. Preferred Method of Communication
2. Privacy Notice (HIPAA Information)
   Please read this notice to understand how CORE may use and share medical information about you, to learn what your rights are as a patient and what duties CORE has regarding the use and disclosure of medical information.

Requesting Medical Records

Patients requesting copy of medical records, please click on this link.

• https://www.swellbox.com/core-orthopedics-wizard.html

All requests are handled by Datavant.

Davatant Pricing – English

Davatant Pricing – Spanish

Datavant can also send you a text with the link to request records, please call 847-242-2836.

Attorneys requesting copy of medical records, please click on the link below.

Once you click on the link, you can either log in or sign up for a Datavant/Ciox account.

You will upload your subpoena or request on the portal. Once processed you will be able to pull the requested records down from the portal.

For any issues on the portal, please contact Datavant Customer Service at 800-367-1500.

• https://www.smartrequest.com/open/login

To check the status of your submitted request, please call Datavant Customer service at 800-367-1500.

Minor Consent

As the parent, if you are unable to attend your child’s visit, please read the Minor Consent form thoroughly and send with your child the day of the appointment.

• Consent Form for Minors

Note: To view or print these forms, you will need Adobe Acrobat Reader.

Preparing For Your Joint Replacement Surgery

• Preparing for Joint Replacement Surgery at the Hospital: Patient Instructions and Checklist

• Preparing for Joint Replacement Surgery at Geneva Surgical Suites: Patient Instructions and Checklist

• Pre-Surgery Checklist for non-joint replacement surgery at Geneva Surgery Center

• Outpatient surgery checklist, clearance, and lab orders for Amita Medical Center and Good Shepherd Hospital