Date of Birth
Requestor Type PatientPatient - Send to Other ProviderAttorney*Business Office (Internal)Disability Determination ServicesFMLAInsurance Payer RequestPersonal Representative (Legal Guardian / Pow)Provider to Provider
*if Attorney Requestor Type is selected, request must originate from the requesting attorney office on letterhead
By submitting this request you acknowledge that payment is required prior to release of records. An invoice will be sent to the email or fax number provided above. Delivery times are from the date payment is received.
Have you been seen at OCI before?
Beech StreetBeech Street/Medicare AdvantageBlue Cross Blue ShieldCignaConsociateHealth Alliance CCO Self-Funded PlansHealthLink HMO (Requires Physician Referral)HealthLink PPOMedicaid (Requires Physician Referral)MedicarePersonal CarePHCSPHAI HMO Illinois (Requires Physician Referral)Quincy Health Care ManagementUnicare HMO (Requires Physician Referral)Unicare PPOOther (Not Listed)
Where you injured on the job? *
Reason for your visit
AnkleElbowFootHandHipKneeShoulderWristSpineOther (describe below)
Have you been seen for this problem before? *
Please choose a physician for your visit
First AvailableDr. AllanDr. BenderDr. HerrinDr. IdusuyiDr. LudwigDr. MaenderDr. MulshineDr. RazaviDr. RomanelliDr. SenicaDr. VanFleet (Requires Physician Referral)Dr. WatsonDr. WerriesDr. Williams (Requires Physician Referral)
Please choose a location for your visit
What time would be better?