Patient registration documents

We’ve listed below some of the documents you may need to acknowledge during your clinic or hospital visit. You’ll receive instructions from the team member who schedules, registers or checks you in about which ones apply for a given visit.

Documents for both clinic and hospital visits

Guarantor Cell Phone Consent

The Guarantor Cell Phone Consent is the agreement of the person financially responsible for an account to receive telephone calls, text messages and other communications from Aurora Health Care on a cellular device.

Financial Responsibility Agreement

The Financial Responsibility Agreement is used when your medical insurance coverage is unable to provide authorization or when you are considered out of network with Advocate Health Care.

Clinic documents

Ambulatory Consent to Treat, Payment and Notice of Privacy Practices

The Advocate Aurora Health Consent to Treat, Payment and Notice of Privacy Practices is your consent to treatment, release of health information necessary for your treatment, and consent for us to submit claims to your health insurance.

Patient Demographic Facesheet, Authorization and Assignment

The Facesheet is a summary of your demographic and guarantor information with additional information related to our privacy practices, your consent to be treated, and your consent to allow us to bill your insurance company and seek payment for the services we provide. When you’re seen in person, we typically ask you to sign a copy of your Facesheet the first time you receive one of the following categories of care:

You can access related information here:

Care Everywhere Opt-Out

Care Everywhere is a functionality that allows us to share and receive your existing medical information with other health systems. The Care Everywhere Opt-Out form is completed if you would like to opt out of this service.

HIPAA Health Plan Restriction Request

This document allows you to request that we withhold providing personal health information to your insurance company for a given date of service or health care item. There are several provisions and restrictions related to this request that you should be sure to review.

Hospital documents

Hospital Treatment Agreement

The Treatment Agreement allows us to provide treatment and diagnostic testing. It also allows us to bill for services rendered. Please refer to the document for additional information.

You can access the brochure information referred to in the Treatment Agreement here:

No Surprise Billing Disclosure

This document explains the protection you now have against surprise bills, what balance billing is, and how to contact Advocate Aurora Health if you feel you have been wrongly billed.

Important Message from Medicare (IMM)

The Important Message from Medicare outlines your rights as a Medicare patient while admitted for inpatient care.

Note: If you have a Medicare Advantage plan, not traditional Medicare, and if you missed the deadline to request an appeal, please contact your insurance company at the customer service number located on the back of your insurance card.

Important Message from Tricare

The Important Message from Tricare outlines your rights as a Tricare patient while admitted for inpatient care.

Medicare Outpatient Observation Notice (MOON)

The Medicare Outpatient Observation Notice outlines your Medicare coverage when you are in observation status in the hospital.

Medicare Outpatient Notice of Coinsurance

The Medicare Outpatient Notice of Coinsurance describes how your care will be billed using hospital-based billing practices.

Advance Beneficiary Notice of Noncoverage

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. This notice explains how you can make an informed decision about care if we expect a service will not be covered.