HOW TO BECOME A PATIENT
Welcome to the Couri Center and thank you for choosing us!
- Please confirm that the Couri Center is in your insurance network. We are in many insurance plans, but since we are a private practice and not owned by any of the hospitals, it is always a good idea to confirm.
- Please complete the following patient forms, as applicable, and return to us.
As soon as we receive your paperwork and enter your information into our system, we will contact you right away to schedule an appointment.
We look forward to partnering in your healthcare! Please call 309-692-6838 with additional questions or click below.
Patient Forms
New Patients - Women
- Patient Information Form (Required for all new patients)
- Gynecologic Questionnaire (Required for all new patients)
- Medical Release Form
- Insurance Card (copy front/back) please mail or email a copy to info@couricenter.com
- Care of Unaccompanied Minor: Consent to Treat
Breast QTscan Paperwork
Applies to new & existing patients. All forms must be completed before scheduling.
QTscan Imaging Procedure Acknowledgment
QTscan Consent to Release Medical Records
QTscan Consent to Send to Another Facility
New Patients - Men
- Male Medical Forms
- Insurance Card (copy front/back) please mail or email a copy to info@couricenter.com
Please complete and email forms to: info@couricenter.com.
It is critical we receive these forms at least 24 hours prior to your appointment time.
Instructions
Print forms and fill in by hand.
- Scan completed documents and email to info@couricenter.com.
OR
Complete forms online as .pdf.
- Please open each form and save it on your computer, preferably add your last name to the file name while saving.
- Open the saved documents and complete each fill-in form.
- Save completed documents.
- Email completed documents as attachments to: info@couricenter.com
CANCELLATION POLICY & FEES
Couri Center & Breast QTscan Policy
We value your time and appreciate your cooperation in keeping our schedule running smoothly for all patients.
- Missed Appointments – A $40 fee applies to all missed appointments.
- Non-Procedural Cancellations – After three late cancellations (less than 24 hours' notice), a $75 fee will apply.
- Procedural Cancellations – After two late cancellations, a $100 fee will apply for procedures like BHRT pellet insertions, colposcopy, LEEP, and skin lesion removal.
- Breast QTscan Cancellations – Please provide 48 business hours' notice for cancellations or rescheduling.
- No-Show Fee – Missed Breast QTscan appointments 10+ minutes late will be charged in full.
- Reminders – We send text and email reminders 2-4 days in advance, but keeping your appointment is your responsibility.