NorthShore Patient Privacy Policy

Notice of Privacy Practices and Policies ( PDF )

NorthShore Health Center’s Continuous Quality Improvement

Authorization to release medical information

NorthShore Payment Policy/Cost of Services

The Health Centers are open to the public.

  • Self pay discounts for health care are determined on a sliding scale according to the responsible party’s income.
  • Cash payments and private insurance are accepted.
  • All clients must pay a minimum fee for each office visit.
  • Medicaid and Hoosier Healthwise payments are accepted.
  • Discounts for dental work are assessed based on the services provided and sliding scale.
  • Payments must be made at the time services are rendered.

NorthShore Health Centers will assess each patient’s insurance plan and financial status prior to rendering services. It is the responsible party’s obligation to furnish all financial documents requested by NorthShore Health Centers.

While we provide a wide range of services, we sometimes refer patients to specialists and others not affiliated with NorthShore Health Centers. Those fees must be negotiated directly by the patient with the provider. NorthShore Health Centers is not involved in these negotiations, and is not responsible for paying such fees.

The new Healthy Indiana Plan (or “HIP 2.0”), www.hip.in.gov is an affordable health insurance program from the State of Indiana for uninsured adult Hoosiers. The Healthy Indiana Plan helps pays for medical expenses and provides incentives for members to be more health conscious. The Healthy Indiana Plan provides coverage for qualified low-income Hoosiers ages 19 to 64, who are interested in participating in a low-cost, consumer-driven health care program.

NorthShore is also an enrollment site for Hoosier Healthwise which provides Medicaid for Pregnant Women & Children. Visit Indiana Medicaid www.indianamedicaid.com for more information.

Speed up your registration process by filling out the packet that applies to you.

Adult Packets
New Adult Patient Registration Packet – Uninsured(extra forms are included to see if you qualify for a discount)
New Adult Patient Registration Packet – Insured

Pediatric Packets
New Pediatric Patient Registration Packet – Uninsured (extra forms are included to see if you qualify for a discount)
New Pediatric Patient Registration Packet – Insured

NorthShore Health Centers’ policy is that a parent/guardian must fill out a consent form giving permission for another adult to accompany their child to the child’s medical, dental or vision appointments. For the protection of your child, we are no longer accepting written permission letters or verbal concept over the phone as acceptable documentation of minor consent. Please print out the Minor Consent Form below and return to any NorthShore Health Centers’ location or stop by one of our locations for a copy of the form. Once you complete the form, it will be documented in the child’s chart and referenced for all future appointments.

Minor Consent Form – Permission to Accompany a Minor

Dental Packets
New Dental Patient Registration Packet
Minor Consent Form – Permission to Accompany a Minor

Optometry Packets
New Optometry Patient Registration Packet

Bright Futures Pre-Visit Questionnaires

Infancy (Prenatal to 11 Months)
2 to 5 Day (First Week) Visit
1 Month Visit
2 Month Visit
4 Month Visit
6 Month Visit
9 Month Visit

Early Childhood (1 to 4 years)

12 Month Visit
15 Month Visit
18 Month Visit
2 Year Visit
2.5 Year Visit
3 Year Visit
4 Year Visit

Middle Childhood (5 to 10 years)
5 Year Visit
6 Year Visit
7 Year Visit
8 Year Visit
9 Year Visit
10 Year Visit

Adolescence (11 to 21 years)
11-14 Year Old Visit
15-17 Year Old Visit
18-21 Year Old Visit


 

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