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.
- MOC596/249 - New Patient History - Knee
- MOC596 - General Medical History Form - For Shoulder and other conditions
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.
- MOC548 - New Patient - Pediatric
- MOC549 - New Patient - Lumbar
- MOC550 - New Patient - Cervical Spine
Thomas J. Mulvey, M.D.
Patrick O'Leary, M.D.
Chukwunenye Kamalu Osuji, M.D.
Brad Roberts, D.O.
James R. Williams, M.D.
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. Requests can be faxed to 309 693-3197, mailed or delivered to the practice. All medical records and imaging requests are performed by RRS medical, our HIPAA compliant Release of Information company. Records are available by mail or email or fax. All Imaging is mailed on a CD due to size. Records are not available for pick up in the office.
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.
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. All Forms should be handed in at the practice or faxed to 309-693-3197. These forms may need to be filled out by you and your surgeon. Please complete your portion prior to submitting them for completion. Also, an authorization to release healthcare information must accompany these forms. The release of information may already be a part of your form but is included in the MOC Form 365 that must accompany all forms. All Forms are completed by RRS Medical, our HIPAA Compliant Release of Information company. Forms are sent directly to the employer or disability company or electronically to the patient thru a secure portal. Forms are not available for pick up in the office. There is a $30 fee to process forms. You will be billed by RRS Medical. Completion of forms may take up to 14 days.