Welcome To The Country Doctor

Appointments (618) 277-3197 Weekday AM Appointments and Exchange (618) 277-3214 E-MAIL The Country Doctor New patients: please include your name, insurance plan, and telephone number.

You will need Adobe Acrobat Reader to view and print the following files.

The new patient will need the following forms to print and fill out prior to the first appointment .Please bring the completed forms to the initial appointment. We have paper forms available to new patients without internet access.

 

You are a new patient if you have never be seen in the office for a visit or if you have not been to an office visit within the last three years.

• Initial Sign In Demographics form General patient information
• Signature form, about HIPPA. Privacy policy (see below)

Please note that cash is the preferred payment method in the exact amount of the insurance-required copayment. Checks are the next favored payment. Mastercard, Visa, Discover, and American Express also are accepted. The Country Doctor is the first St. Clair County practice to publish its common fee schedule.

Patients will need to review the following forms - note you can review them without printing them:

• HIPPA Summary Page 1 Page 1 of the Privacy Policy Text
• HIPPA Summary Page 2 Page 2 of the Privacy Policy Text
• General Policies Summary
• Health Recommendations Page 1
• Health Recommendations Page 2
• Business Card

Commonly used forms

• School Physical Form from the State of Illinois Update for new 2012 requirements
• Sports Physical Form for Illinois
• Illinois Department of Motor Vehicles Page with the handicap sticker as an Adobe Acrobat document.
• Vaccine Handouts

Adobe.com for Adobe Acrobat Reader, to view .PDF files.

If you are transferring from another physician's practice, had your physician leave the area, or recently moved to the area, you will need this form:

Old Records Request

Please send this form directly to your former physician's practice.

Optional, but useful forms:

• Map to our practice (note the Casey's is now Midwest Petroleum)
• Country Doctor Biography/Credentials Dr. David Mitchell's biography

 

If you are requesting a copy of your medical records for yourself or are moving from the area:

 

Personal request of routine medical records

 

Highly private information record request

The amount a physician can charge for copying medical records in the state of Illinois is regulated by Illinois General Assembly. The Country Doctor, Ltd. follows the fee schedule established by state and Federal laws. There is a minimum $25 charge to transfer records.

Adobe.com for Adobe Acrobat Reader, to view .PDF files.

*Accepting new patients from insurance plans where we have been credentialed.

Home	Hours of Operation	NEW PATIENT FORMS
Accepted Insurance Plans	Physician Biography	Driving Directions/Maps
Office Pictures	Medication Questions	Links & Patient Handouts
	Health Screening Recommendations	Address Directory

*Clicking one time on any link will take you to the referenced web page.

 

 The Country Doctor, Ltd.

2310 Country Road

Shiloh, IL 62221-2570

Voice (618) 277-3197

Exchange (618) 277-3214