BECOME A MEDICAL PATIENT

APPLICATION ASSISTANCE

Available: Monday - Thursday 11am - 6pm

Kristen Pirelli  Outreach Coordinator

Phone: (773) 590-2816   Email: kristenpirelli@gmail.com

  • Autism

  • Agitation of Alzheimer’s disease

  • HIV/AIDS

  • Amyotrophic lateral sclerosis (ALS)

  • Anorexia nervosa

  • Arnold-Chiari malformation

  • Cancer

  • Cachexia/wasting syndrome

  • Causalgia

  • Chronic inflammatory demyelinating polyneuropathy

  • Chronic pain

  • Crohn’s disease

  • CRPS (complex regional pain syndrome Type II)

  • Dystonia

  • Ehlers-Danlos syndrome

  • Fibrous Dysplasia

  • Glaucoma

  • Hepatitis C

  • Hydrocephalus

  • Hydromyelia

  • Interstitial cystitis

  • Irritable bowel syndrome

  • Lupus

  • Migraines

  • Multiple Sclerosis

  • Muscular Dystrophy

  • Myasthenia Gravis

  • Myoclonus

  • Nail-patella syndrome

  • Neuro-Bechet’s autoimmune disease

  • Neurofibromatosis

  • Neuropathy

  • Osteoarthritis

  • Parkinson’s disease

  • Polycystic kidney disease (PKD)

  • Post-Concussion Syndrome

  • Post-Traumatic Stress Disorder (PTSD)

  • Reflex sympathetic dystrophy

  • Residual limb pain

  • Rheumatoid arthritis

  • Seizures (including those characteristic of Epilepsy)

  • Severe fibromyalgia

  • Sjogren’s syndrome

  • Spinal cord disease (including but not limited to arachnoiditis)

  • Spinal cord injury is damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity

  • Spinocerebellar ataxia

  • Superior canal dehiscence syndrome

  • Syringomyelia

  • Tarlov cysts

  • Tourette syndrome

  • Traumatic brain injury

  • Ulcerative colitis

  (passport photo must be in jpg format)

 

  • Proof of Age & Identity: 1 Form

Valid State ID

Valid Driver's License

Valid U.S. Passport​

  • Proof Of IL Residency: 2 Forms

Utility Bill

Bank Statement

State ID/License

*State ID, License/Passport must be valid.

*Veterans, Disability, Senior, & SSDI Recipients Eligible for discounts.

*Veterans may use last 12 months active VA Records in place of a Physician Certification.

*Electronic Physician Certification

Must be submitted within 90 days

*Up to 3 Caregivers (Optional)

$25/yr/each

Can Purchase on Patient's Behalf

*Caregiver Attestation PDF Download
 (Only Download If You Are The Caregiver)

*Must Be Medical Patient