"Excellence & Innovation from
Caring Physicians"
On Your First Visit
Pain Gauge
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FYI from OCI News
Insurance Information
FAQ
HIPAA
Hospital Affiliations
Where Does it Hurt?
Appointment Request Form
Interactive patient education
Please do not fill out this form if it is an emergency. Please call the trauma nurse at 862-0624
First Name:
Last Name:
Date of Birth: (mm/dd/yyyy)
Daytime Phone Number: (where you can reached between 8am-5pm) (xxx)xxx-xxxx
Home Phone Number:
Email Address:
Have you been seen at OCI before?
yes
no
Insurance Plan:
Blue Cross Blue Shield
Cigna
Consociate
Health Alliance PPO and Self-Funded Plans
Healthlink PPO
Healthlink HMO (Requires Physician Referral)
Medicaid (Requires Physician Referral)
Medicare
PHAI HMO Illinois (Requires Physician Referral)
PHCS
Unicare PPO
Unicare HMO (Requires Physician Referral)
Quincy Health Care Managment
Primary Care Physician:
Were you injured on the job:
Yes
No
Reason for visit:
Spine
Shoulder
Elbow
Wrist
Hand
Hip
Knee
Ankle
Foot
Other (describe below)
If you chose "other", please describe:
Have you been seen for this problem before?
Yes
No
If yes, by who?
Describe your symptoms:
Please choose a Physician for your visit:
First Available
Dr. Romanelli
Dr. Ludwig
Dr. Herrin
Dr. VanFleet (physician referral required)
Dr. Senica
Dr. Mulshine
Dr. Smucker (physician referral required)
Dr. Sigle
Dr. Williams (physician referral required)
Dr. Mack (physician referral required)
Dr. Scott
Dr. Werries
Please choose a location for your visit:
First Available
Springfield
Jacksonville
Carlinville
Lincoln
Litchfield
Petersburg
Rushville
Which appointment would be better?
AM
PM
Comments:
