In an effort to improve your experience with Midwest Orthopaedic Center, please take a moment to review and complete the forms associated with your first visit.  Should you have any questions, please do not hesitate to contact us at (309) 691-1400.

Patient Pre-Visit Forms

 

Please find your doctor and print his selected forms.

 

Jeffrey W. Akeson, M.D.

Robbye Bell, M.D.

Adam Colen, D.O.

Nirain A. D'Souza, M.D.

Fahed El Chami, D.P.M.

Michael J. Gibbons, M.D.

Brent C. Johnson, M.D.

Luke Luetkemeyer, M.D.

John D. Mahoney, M.D.

Michael S. Merkley, M.D.

Donald A. Mitzelfelt, M.D.

Daniel S. Mulconrey, M.D.

Thomas J. Mulvey, M.D.

Patrick O'Leary, M.D. 

Chukwunenye Kamalu Osuji, M.D. 

Brad Roberts, D.O.

James R. Williams, M.D.

Rehabilitation Services

 

Requesting your medical records: Should you need to request your Medical Records be sent to another facility for treatment or for your own personal file, please complete the forms below and return to Midwest Orthopaedic Center for processing. 

MOC534/535 - Records Release Request  | MOC534-A - Medical Records Fees

Permission to Treat a Minor without a Parent or Guardian Present: A parent or legal guardian must accompany any minor (under the age of 18) to the first appointment. If parent or legal guardian cannot accompany the minor for subsequent visits, the following form must be completed, signed, witnessed and sent with the person accompanying the minor to the appointment.

MOC523 - Consent to treat without parent

FMLA/Disability Forms: An injury or surgery may require you to have time off from work, please contact the human resource department at your company for the correct forms and have them faxed to 309-693-3197.  These forms may need to be filled out by you and your surgeon. Also, an authorization to release healthcare information must accompany these form. The release of information  may already be a part of your form or one of our release of information forms MOC 535 can be filled out.  There is a $10 fee to process each form. Completion of forms may take up to 14 days.

MOC 535 Authorization to Release Healthcare information

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