Dr. ALan Bain, D.O.
  • WE'RE HERE FOR YOU!
  • THIS IS US!
  • SERVICES AND TREATMENT
    • Covid-19
    • Thyroid Treatment/Therapy
    • Lyme's Disease
    • Candida/Yeast Overgrowth
  • Patient forms
  • SCHEDULE APPOINTMENT
  • CONTACT US
  • More
    • WE'RE HERE FOR YOU!
    • THIS IS US!
    • SERVICES AND TREATMENT
      • Covid-19
      • Thyroid Treatment/Therapy
      • Lyme's Disease
      • Candida/Yeast Overgrowth
    • Patient forms
    • SCHEDULE APPOINTMENT
    • CONTACT US
Dr. ALan Bain, D.O.
  • WE'RE HERE FOR YOU!
  • THIS IS US!
  • SERVICES AND TREATMENT
    • Covid-19
    • Thyroid Treatment/Therapy
    • Lyme's Disease
    • Candida/Yeast Overgrowth
  • Patient forms
  • SCHEDULE APPOINTMENT
  • CONTACT US

ALERT! New & Established Patients

Our practice requires all of our patients to have updated Patient Forms (required) on file. 

Failure to have completed forms will result in rescheduling or cancellation of your appointment. 

Please call or message us if you have any questions. 

Patient forms

Adobe E-Signature

2023 New Patient Forms (Required)

All patients' must have updated forms on file. This file contains information regarding demographics, insurance and medical consent forms. Forms must be completed entirely with your full legal name before your appointment.

2023 Upload Your Health Records (Required)

You may submit your records, test results, consult notes and medication lists electronically or via fax to: 

877-325-2058

2023 Informed Consent (Required for Off-Label Treatment)

All patient's requesting an appointment for a non-covered service, or for the use of off label treatments/therapy must have this form on file. This form must be filled out in its entirety before your appointment. 

2023 Insurance Update

New insurance plan? You can easily update your insurance with us by completing this form to avoid unnecessary delay in claim processing or charges to your account. You may also request to have your statements automatically paid by completing the "Card on File" portion. 

2023 Release of Medical Records

We understand you may want others to have access to your health records. Please complete this form in its entirety if you wish to request the release of your records. NOTE: Processing may take 7-10 days. 

2023 Financial Hardship Application

No insurance? We are committed to helping everyone get their health back on track. Our practice offers self payment options as well as payment plans for those that qualify. 

  • SCHEDULE APPOINTMENT

Chicago Health And Wellness Alliance

8 S. Michigan Ave, 1403 Chicago, IL 60603

Ph 312-236-7010 Ext 2. | Fax 877-325-2058

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