Contact Us/ Information Request

Introduction

Please use the form below to contact us for information about the program, to schedule an informational session or request informational and promotional items. You can also call 1-866-986-2778 or email us at docassistil@uic.edu.

Other requests

Quick links to other forms:

Contact Us and Information Request

Please do not enter HIPPA-protected information in the form below.

Name * Required
First Last
Provider Type/ Credential * Required
Other Provider Type / Credential
Provider Specialty * Required
Other Provider Specialty
Practice Type * Required
Practice Type, Other
Name of Facility/Practice * Required
Facility/ Practice County
Phone * Required
Email * Required
Enter Email Confirm Email
Would you like to schedule an informational session with an Illinois DocAssist consultant? * Required
- Yes
- No
Informational sessions are offered virtually and allow a provider or a group of providers to meet Illinois DocAssist staff and consultants and familiarize themselves with the programs free services.
When would you like to schedule an informational session?
Please provide dates and times that you or your practice group are available.
Approximately how many providers do you expect to be present during the informational session?
How much time can you allow for the informational session?
- 15 minutes
- 30 minutes
- 45 minutes
- 1 hour
Content can be adjusted based on time allowed. Longer informational sessions allow for more opportunity for Q & A and case examples.
Would you like to be mailed some Illinois DocAssist informational and promotional items? (brochures, magnets, pens etc..) * Required
- Yes
- No
How many promotional items are you requesting?
Facility/Practice Address (If you would like promotional items mailed to you)
Street Address Address Line 2 City State ZIP Code
Please type any other information about your inquiry and an Illinois DocAssist staff member will respond within one business day. (Please do not enter any HIPPA protected Information here)

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IllinoisDocAssist (866) 986-2778

Contact Us/ Information Request

Introduction

Other requests

Quick links to other forms:

Contact Us and Information Request

Department of Medicine
Medicaid Advisory Unit