Thank you for visiting our website prior to your appointment at Great Plains Orthopaedics. The following forms are being provided for your convenience. At this time, the forms are available to be printed out and completed so you can bring them in with you. They will not be electronically submitted. You will need Adobe® Reader® to download the forms. If you do not have Adobe® Reader®, you can download it here.

For answers to commonly-asked questions, click here.

Financial Agreement Form

This form explains your financial responsibility, assignment of benefits, release of information and receipt of our Notice of Privacy Practices. In addition, it provides space for you to indicate with whom we may discuss your health, such as a spouse, parent, adult child or close friend. Please read this form carefully and print it out. Then complete, sign and initial.

Parent / Guardian Authorization for Treatment Form

It is our office policy not to treat minor children unless they are accompanied by a parent or guardian. If at any time in the future you think you will be sending your minor child in for medical treatment without being accompanied by a parent or guardian, we need authorization to treat.

Patient Medical History Form

If you are a new patient or have not been seen for six months, please complete this form prior to your visit. The physicians have established a protocol that each patient’s history is to be updated every six months or for each new orthopaedic condition. A patient’s health can change quickly and we want to have the most current information available to treat our patients.

Privacy Practices Notice

Your privacy is very important to us. Please download our Notice of Privacy Practices by clicking above.

Workers’ Compensation Authorization Form

All workers’ compensation claims must have written authorization of the claim from your employer or carrier prior to your appointment. Please take this form to your employer for completion prior to your scheduled appointment.

303 N. Wm. Kumpf Bl.
Peoria, IL 61605
P. 309.676.5546
F. 309.676.5045

7800 N. Sommer St.
Suite 608
Peoria, IL 61615
P. 309.689.0500
F. 309.689.9706

7800 N. Sommer St.
Suite 506
Peoria, IL 61615
P. 309.589.2767
F. 309.692.1424