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Past Medical History
Past Medical Problems
Asthma
Cancer
Diabetes
High Blood Pressure
Heart Disease
Stroke
Other Problems
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Have you had any surgery in the past?
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No
Do you smoke?
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I don't smoke
Do you have any other health insurance?
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Primary Care Physician (PCP)
Abbas, Zareena Abbas
Ahmed,Farooq Ahmed
Ahmed, Misbahuddn Ahmed
Akere, Ayoade Akere
Al Shobaki, Mansour Al Shobaki
Ali, Muhammad
Askari, Ruhi Askari
Durrani, Abdul Durrani
GEFCC/ Seneca Health Ctr
GEFCC/ Summit Health Ctr
GEFCC/ McHenry Health Ctr
GEFCC/ Streamwood Health Ctr
GEFCC/ Creekside Health Ctr
GEFCC/ Lake Health Ctr
Hamdard, Ctr Clinic Hamdard
Hosain, Farzana Hosain
Humayun,Shaheen Humayun
Hussain, Ahmed Hussain
IFN Clinic at Islamic Foundation North
Khan, Gowhar
Mallick, Naveed Mallick
Mazheruddin, Farkhunda Mazheruddin
Mazheruddin,Farkhunda Mazheruddin
Mohiuddin, Ali Mohiuddin
Qadir, Abdul Qadir
Quadri, Syed Quadri
Saeed, Asim M. Saeed
Saeed, Omar M. Saeed
Saaduddin, Syed Saduddin
Shah, Nasreen Shah
Shahzad,, Muhammad Shahzad
Sharif, Sitara Sharif
Sheikh, Asrar Sheikh
Syed, Zainulabuddin Syed
Thaseen, Sabiha Thaseen
Thaseen, Sabiha Thaseen
Toor, Mohammad Toor
Warsi, Syed Warsi
Zaheer, Badar Zaheer
Nafees Ahmed
Alia Siddiqi
Thana Tarsha
SAMS Free Specialty Clinic
Mohammed Adil
Syed F. Hussaini
Waheeda Iqbal
Sher Ahsan Niazi
Abdelraouf Oubaid
Mohiuddin, Maaz
Siddiqui, Ayesha
Tahir Abbasi
M. Tarek Alahdab
Muhammad Ali
Safdar Ali
SAMS Free Specialty Clinic
Mohammad Toor
Mohammad Toor
SAMS Free Specialty Clinic
Muhammad Kudaimi
M. Murtaza Arain
Rabia Bhatti
Farheen Shah-Khan
Aamir Memon
Muhammad Zafar
Muhammad Zafar
Mohammad Al-Khudari
Mohammad Al-Khudari
Mohammad Ahsan
Hamdard Center Clinic
Hamdard Center Clinic
Kutub Uddin
SAMS Free Specialty Clinic
Anwar Mohiuddin
Khan
Naveed Mallick
Asim M. Saeed
Azher Quader
Tariq T. Ahmed
Mated Masood
A.S. Jabbers
A.S. Jaber
Naveed Saeed
Naveed Saeed
Naveed Saeed
Parveen Ahmed
Parveen Ahmed
Ilyas Ahmed
Adil Asim
Firdaus Jafri
Mimi V. Johnson
M. Khan
M. Khan
Hammad Khan
Nida Marouf
Salmaan Poothawala
Salman Poothawala
Haroon Shah
Haroon Shah
Imaad Shaikh
Imaad Shaikh
Irving Park Dental
Hidayathulla Khan
Hidayathulla Khan
Khalilur Rahaman
Atha Hyderi
Srinivas Jairam
Srinivas Jairam
Asif Khan
Fahad Khan
Hooman Keshavarzi
Murad Abdel- Qader
Murad Abdel-Quader
Khalid Husain
Kareem A. Raheem
Any Lab Test Now
Central Clinical Labs
Citilabs Inc
Med Lab Inc
Medstar Lab
Northshore Clinical Labs
Oakcrest Medical Lab
Simple Labs
Unilab Inc
Imaging Centers of America
Marayah Diagnostic Imaging Center
Medical Imaging Center
Medquest Radiology Center
MedLife Diagnostic Center
Midwest Imaging & Diagnostic Ctr
Touhy Diagnostic
Compassionate Care Pharmacy
1st Family Pharmacy
Exclusive Pharmacy
Healthy Pharmacy
Monick Pharmacy
Naperville Pharmacy
Are you taking any medications?
Yes
No
I DECLARE THAT I HAVE NO HEALTH INSURANCE COVERAGE FOR THE SERVICES BEING PROVIDED BY COMPASSIONATE CARE NETWORK, CCN.
I FURTHER DECLARE THAT MY BANK ACCOUNT AND COMBINED ASSETS INCLUDING PROPERTY, VEHICLES, CASH, AND JEWELRY ARE LESS THAN $5,000. MY ANNUAL INCOME IS NO MORE THAN $16,000. I ACKNOWLEDGE THAT ALL INFORMATION PROVIDED ABOVE IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
ARE YOU ZAKAT ELIGIBLE
CHECK THIS BOX IF YOU AGREE THAT ALL STATEMENTS ARE TRUE, AND THAT YOU ACKNOWLEDGE THAT YOU ARE THE PERSON FOR WHOM THIS FORM IS FILLED OUT.
I DECLARE THAT I HAVE NO HEALTH INSURANCE COVERAGE FOR THE SERVICES BEING PRIVIDED BY CCN. I DECLARE THAT MY ANNUAL INCOME IS BELOW THE 400% FEDRAL POVERTY GUIDELINE THRESHOLD. I ACKNOWLEDGE THAT ALL INFORMATION PROVIDED ABOVE IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AGREE TO PAY THE FEE OF $25.00 FOR EACH OFFICE VISIT TO THE CCN PHYSICIAN ASSIGNED TO ME. I ALSO UNDERSTAND THAT LAB AND X-RAY CHARGES WILL BE ADDITIONAL AND WILL BE PAYABLE BY ME TO THE PHYSICIAN'S OFFICE OR TO THE FACILITY DIRECTLY. IF I NEED SPECIALIST CONSULTATION AND SUCH A CONSULTANT IS NOT AVAILABLE WITHIN CCN THEN I WILL SEEK A CONSULTANT OUTSIDE THE NETWORK AND WILL BE WILLING TO PAY THE CONSULTANTS REGULAR FEE. IN CASE OF A MEDICAL EMERGENCY, I AGREE TO SEEK EMERGENCY ROOM CARE AT THE NEAREST HOSPITAL FACILITY AND WILL NOT HOLD ANY CCN PHYSICIAN LIABLE FOR MY CARE. I UNDERSTAND THAT PREGNANCY CARE IS NOT INCLUDED IN MY MEMBERSHIP. I AGREE TO PAY THE MINIMUM MEMBERSHIP FEE OF $60.00 FOR SIX MONTHS (INDIVIDUAL) or $90.00 FOR SIX MONTHS (FAMILY), TO JOIN THE NETWORK UNLESS OTHERWISE WAIVED. I AGREE TO ENROLL FOR SIX MONTHS (INITIAL) AND TWELVE MONTHS (SUBSEQUENT RENEWALS). MAKE PAYMENT TO COMPASSIONATE CARE NETWORK. MAILING ADDRESS: 6348 N. MILWAUKEE AVE., #215, CHICAGO, IL 60646.
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