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Your surgeon has referred you for outpatient surgery at Belmont / Harlem Surgery Center. We must know your medical history prior to your procedure.

The Online Pre-Operative Medical Assessment must be completed As Soon As Possible BEFORE your surgery. You will need the following information to complete the form.


  • List of all medications

  • List of allergies and sensitivities

  • Name and date of previous surgeries

  • Your medical history

Completing the secure Online Medical Assessment is easy, and all of your information is kept confidential.

  • Complete all sections.

  • If a section does not apply select the check box for “No Issues".

  • Be sure to include a complete medical history: including conditions you currently have, take medication for, or conditions you had in the past.

User tip: If completing this survey on your smart phone, rotate your device sideways (landscape) for larger text.

Upon receipt at Belmont / Harlem Surgery, someone from our team will call you regarding your surgery. Please see our Patient Guide to Surgery section with preparation for surgery instructions.



You will enter our facility at 3115 N. Harlem Ave. We are located on the main level. When registering at reception you will need to provide your current medical insurance card or Medicare information. We will submit your insurance claim for you.


If you have insurance, you will need to pay the co-insurance and deductible amounts. Payment is due at time of service. We can work with other plans, and self-pay patients.

You will be billed separately for diagnostic testing, your surgeon’s fees and fees associated with anesthesiology, radiology and pathology involved with your procedure. 

If your insurance company is not listed below, it may be considered to be part of one of the other networks. If you do not have medical insurance, are uninsured or a self-pay patient, then payment can be made by check, money order or credit card. We do not accept cash as a form of payment for your procedure.


Please call our office at 773-889-2000 and ask to talk with the billing department for more information.


In most cases we can accept self-pay patients. The self pay option is for patients who do not have insurance or who choose to pay for their treatment directly rather than using private health insurance. If paying out of pocket is an option for you, we included information where you can learn more about surgery center costs. Speak to one of our representatives to learn more. 


Belmont / Harlem Surgery Center has established arrangements with several different types of health care insurers. Review the links below for information relevant to your coverage. Many health insurance websites provide information on where to find in-network services.


Blue Cross Blue Shield

United Healthcare



Resurrection Physicians Provider Group (RPPG)




What's New?

  • On July 29, 2020 the HHS office of the Assistant Secretary for Planning and Evaluation (ASPE) released a report on addressing surprise billing in response to a requirement in Executive Order 13877 “Improving Price and Quality Transparency in American Healthcare to Put Patients First.” The report explains why federal legislation is needed to address surprise billing.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. If you have questions about your procedure, please call us directly.


Frequently our patients ask common questions before going in for their procedure. We have tried to address them here. If you still have questions after reviewing this section, please contact the Belmont Harlem Surgery Center at (773) 889-2000 if you have any questions or concerns.


Our nurse will contact you before your procedure to confirm your scheduled arrival time and to remind you of pre-operative instructions. If you do not receive a message from our nurse 24 hours before your scheduled appointment, please contact us at (773) 889-2000 to confirm.

  • Plan to arrive as you have been directed.

  • DO NOT eat or drink anything, including water, after midnight (12 a.m.) on the day of the procedure, unless otherwise directed by your surgeon.

  • If you take blood pressure or heart medication, take these with a small sip of water on the day of the procedure.

  • Make arrangements for a responsible adult to remain with you at the Belmont Harlem Surgery Center and to take you home.

  • Parents of minors must remain in the waiting room during their child’s surgery.


  • Leave all of your valuables at home.

  • Remove all make-up and jewelry.

  • Wear loose-fitting, comfortable clothing.

  • You should bathe or shower the morning of your surgery.

  • Brush your teeth but do not swallow the water used to rinse your mouth.

  • Bring a list of medications you take regularly.


Check in at the registration desk. Please be sure to bring your insurance card, a photo ID and any requested forms. You will be escorted to an area to change into a surgery gown and any necessary pre-operative testing will be completed. You will be asked to remove contact lenses, hearing aids and dentures. An anesthesiologist will consult with you prior to your procedure.



You will be taken to the Post-Anesthesia Care Unit, where trained nurses will monitor your vital signs until you are allowed to return home. Before you are discharged, you will be served a light snack. Our nurse will personally review your post-operative instructions with you.


Our recovery staff will contact you within 24-72 hours following your procedure. If you have any questions prior to that call, we ask that you contact your physician. It is important for you to follow your physician’s instructions regarding diet, medications, bathing, driving and activity. Contact your physician if you experience any complications. We encourage you to eat lightly and to avoid high fat foods for the first 24 hours after your procedure.


If you have additional questions, you can wait for the staff member to call you regarding you pre-surgery instructions and surgery preparations. Otherwise, please call our center at (773) 889-2000*


*Voice messages left for customer service are protected under HIPAA privacy laws. Text Messages are not protected under the HIPAA privacy laws. Please visit our website privacy policy for full disclosure. Messaging and data rates may apply. Belmont / Harlem Surgery Center is not responsible for any delays upon sending or receiving communications.

Thank you for selecting Belmont / Harlem Surgery Center for your procedure.

Prices listed on third party websites are not guaranteed and should only be used for reference. B/HSC is not affiliated with Healthcare Bluebook or Care Credit.

Patient Guide
Payment Options We Accept

Medicare Users can use Medicare's Procedure Price Look up tool to compare the national average price for procedures done in ambulatory surgical centers.  Medicare allows you to search by procedure name or code.

Healthcare Bluebook is a well known online tool to compare out of pocket medical expenses including what a surgery center procedure might costs.

Belmont / Harlem Surgery Center accepts CareCredit®. Care credit is for patients who may need financial help, without delaying appointments or treatment. With Care Credit you can pay for out of pocket expenses for your surgery right away and then make convenient monthly payments.

Learn more about how to apply for care credit.

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