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Jerome Hoeksema, M.D. | Laurence A. Levine, M.D. 1725 West Harrison Street, Suite 917, Chicago, IL 60612 | 312.563.5000 |
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| Forms
For your convenience, we have made our forms available to you on this Web site in a printer-friendly format. By completing these forms ahead of time, you will be able to fill them out in privacy and we can check you in more quickly when you arrive at our office. All patients are required to fill out the first four forms listed. Dr. Levine requires completion of certain questionnaires listed below. Please review the list to see if those questionnaires apply to your situation. |
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Registration Form - Required Demographic, insurance, and referring physician information |
| Signature Form - Required Allows our clinic to bill your primary and secondary insurance |
| History Form - Required Indicate the reason for your visit and your health history |
| Receipt of Notice of Privacy Practices - Required Signature acknowledges that you have received our Privacy Policy which is available on this Web site and in our office |
| Questionnaires: If you are scheduled to see Dr. Levine for the first consultation or office visit, please fill out the following questionnaires which are pertinent to the reason you are seeing him. These forms must be completed before the doctor can see you. |
| Erectile Dysfunction IIEF (International Index of Erectile Function) |
| Peyronie's Disease |
| Male Fertility |
| Health Calculators: The following forms help our physicians diagnose and treat your health condition. Please print and fill out ADAM questionnaire if you have or suspect you have erectile dysfunction (ED) or a testosterone-related condition. Please print and fill out the IPSS questionnaire if you have or suspect you have a condition related to your prostate. |
| ADAM Questionnaire Screening tool for potential testosterone deficiency |
| IPSS (International Prostate Symptom Score) Questionnaire Tool for assessing symptoms of prostatism |
| Authorization for Release of Confidential Health Information: The following forms will facilitate the process of sending your records to you or your physician or having your records sent to our office before your appointment. |
| From Urology Specialists to Third Party Our office needs this form dated, signed, and on file before we can mail out medical records. Please note that for confidentiality purposes we do not FAX medical records. |
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From Third Party to Urology Specialists You can use this form to authorize a third party to release of your records to our office. The party releasing your records will need to keep this form on file. |
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