If you are an existing patient needing help, we have a few options for you.
1. Use our patient portal.
2. OR – Call us at 630-371-9980
3. OR – If you are having any difficulty with the phone system, please email at PatientHelp@painchicago.com
4. OR – fill out the following form:
Please complete pain diagram and bring to your appointment. If there are any Demographic/Insurance changes or HIPAA updates, please complete and bring to your appointment. Thank you.
- Patient Demographics
- Signature Sheet
- Pain Diagram
- HIPAA Form
- ARI Form
- ICC Form
- COVID 19 Consent to Treatment
- Requisition for Forms – FMLA and Other
- Authorization for Release of Medical Records
(Please complete a request for form and fax it to our office at 630-371-1555. There is a 10 business day turnaround time)
- Self Pay Policy Form
- New Patient Packet
- MR Release Form
- Curbside Office Visit Instructions
- Request Medical Records
- Benefit Assignment Policy
- ICC (Portal)
- Notice of Privacy Practices
- Opioid Policy
- Controlled Substance Agreement
- Opioid Consent for Treatment
- Controlled Substance Policy
Patient Art states he has suffered from neck pain since he was a child, the pain became worse when he was involved in a car accident years later. Art has tried every avenue to relieve the pain; it was not until he was referred to Dr. Glaser who worked hard to find a plan that worked specifically for him. Art is not pain free but does say his pain is manageable and will continue to follow Dr. Glaser’s treatment plan. We thank Art for sharing his story!
I am forever grateful for both the pain relief and because now I don’t need pain medication to get through the day,” Carol said. “I have lunch dates with friends, spend time with my grandchildren and even sat through a 3-hour play comfortably – all without having to recuperate for days afterward.