Orthopedic Institute of Pennsylvania - Appointment Request Form

Ph: (800)834-4020 . (717)761-5530 . Fax: (717)737-7197

Orthopedic Institute of Pennsylvania Appointment Request Form
(for non-emergencies only)

PLEASE DO NOT FAX FRACTURES OR SAME DAY APPOINTMENTS. YOU MAY CALL THE OFFICE TO SCHEDULE THESE.
PHONE NUMBER (717)-761-5530 / FAX NUMBER (717)-901-4247

Referring Office Information:
Date Time
Referring Office
Referring Physician
Referring Office Phone
Referring Office Fax
Reason for Visit

Patients Name:
Last Name
First Name
Middle Name

Social Security Number
Date of Birth

Phone:
Primary Phone # Alt Phone #

Insurance Information:
Primary Insurance
Secondary Insurance

WE DO NOT ACCEPT:
Amerihealth Mercy / Geisinger / Optimum Choice Insurance.
We are out of Network with United Healthcare.

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Please check all tests that were done.
XRAYS, MRI, CTSCAN,
BONESCAN, DOPPLER, EMG/NCS, LABS

Patient must hand carry films to their appointment.
Please fax all reports to our office (717) 737-7197

Referral Appointment:
Appointment Date
Appointment Time
Office Location
OIP Physician Requested

OIP Notes Area
OIP left a message on.
Date
Scheduler

If the patient does not return our call within 3 days we will fax
the form back to you for your records.

Your patient has not returned our call to schedule an appointment.
Date
Scheduler

E-mail transmission cannot be guaranteed to be secure or error-free as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. The sender therefore does not accept liability for any errors or omissions in the contents of this message, which arise as a result of e-mail transmission.

I have read and understand the statement above.

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