FICOM HEALTH CARE FORMS

FICOM FAX NUMBER: 417-832-1193

Patient Forms

Faith Immediate Care & Occupational Medicine’s (FICOM) new patients can save time during their first appointment by completing the patient forms prior to their visit. You can either print and fill in the information requested and bring the completed form(s) with you to your appointment or you can fill out the forms online. Have questions? Call us at 417-832-1117.

Direct Primary Care Plan Forms

Direct Primary Care Membership Agreement

Payment Authorization Form

Occupational Health Services Forms

Employer Authorization Form

Company Protocol Form

DOT Physical Exam Form (MCSA-5875)

Call FICOM at 417-832-1117 to schedule an appointment or send an email.

CLINIC HOURS
Monday – Friday: 8:00 a.m. – 5:00 p.m.
Closed: Weekends and Holidays
~ Last patient check-in at 3:30 p.m. ~

EMERGENCY SERVICES
Workplace injuries seen 24/7
Call 417-440-2893
~ After hours fee may apply ~

LIFE THREATENING EMERGENCIES
CALL 911

Faith Immediate Care logo

1308 N. Glenstone Ave.
Springfield, MO 65802
417-832-1117
Fax: 417-832-1193
[email protected]

24/7 WORK COMP INJURY SERVICES — CALL 417-440-2893