Mon-Fri 8 AM-5 PM

+1-402-758-5800

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Call to Schedule

20+ Years

Internal Medicine

Board-Certified

Providers in Omaha

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Patient Registration Forms

Complete Your Forms Online or Download

Welcome! To make your first visit as smooth as possible, you can fill out your patient registration form directly on this page. It’s quick, secure, and saves time at check-in.

Once you’ve completed the form below, just click “Download” to save a copy with your information already filled in. You can print it and bring it with you to your appointment, no handwriting required.

A happy family and clients of Internal Medicine and Family Physicians of Omaha.

Need Assistance?

We’re here to help.

If you have any questions while completing your form or prefer to fill it out by hand, feel free to reach out. Our team is happy to walk you through it or provide a paper copy.

(402) 758-5800

Prefer to Fill It Out by Hand?

Download a blank version?

If you’d rather complete the form manually, you can scroll to the bottom and click download PDF to get the blank version and fill it out at your convenience before you arrive.

Patient Registration Form

TODAY'S DATE:

Patient Registration

First Name *

Middle Initial

Last Name *

Preferred Name (if different than legal name)

Date of Birth *

Gender

Social Security #

Marital Status

Address *

City *

State *

ZIP *

Home Phone

Work Phone

Cell Phone

Patient Email

Employer

Occupation

Emergency Contact

Phone

How Related?

Guarantor (Person Responsible for Bill)

Same as Patient

Name

Relation to Patient

Address

City

State

ZIP

Employer

Phone

Date of Birth

Social Security #

Home Phone #

Spouse Information (If Married)

Spouse's Name

Spouse's Employer

Date of Birth

Social Security #

Insurance Coverage Information

PLEASE BE PREPARED TO PRESENT YOUR INSURANCE CARD(S) AT EVERY VISIT

Primary Insurance

Insurance Company

Address

Policy #

Group #

Subscriber

Date of Birth

Relation to Patient

Secondary Insurance

Insurance Company

Address

Policy #

Group #

Subscriber

Date of Birth

Relation to Patient

Insurance and Assignment of Benefits Authorization Information

I hereby authorize treatment of the above-named patient and agree to pay all charges for treatment regardless of insurance coverage or the pendency of insurance claims.

I authorize the release of all medical information to the above insurance carriers that is pertinent to my medical care and necessary to process my insurance claims. I will assign all medical and surgical benefits to Internal Medicine Physicians P.C. A photocopy of this form shall be as valid as the original. I understand that I can withdraw this medical benefit assignment at any time by notifying this office in writing.

I have read this information thoroughly and understand it.

PATIENT SIGNATURE

DATE

(PARENT OR LEGAL GUARDIAN IF MINOR)

Financial Agreement / Assignment of Benefits

Financial & No-Show Policy:
Payment in full is required at the time services are rendered. If you are unable to remit payment in full, you may be required to speak with a patient account representative to make alternate payment arrangements.

As a courtesy, we will file claims with your primary and secondary insurance (if applicable) providing we have your Assignment of Benefits and current and accurate insurance information from you. Payment for services is ultimately the patient's responsibility. NOT ALL SERVICES ARE A COVERED BENEFIT OF ALL PLANS.

No-Show/Late Arrival Policy:
A minimum 2-hour notice is required to cancel appointments. If the required notice is not received, you will be charged a $50.00 fee. This fee is NOT covered by your insurance. If you are more than 10 minutes late for your appointment, you may be required to reschedule.

I have read and agree to the terms and conditions set forth above. I understand that I am responsible for and agree to pay all charges regardless of insurance coverage or pendency of claims. I authorize the release of all medical information necessary to process my health insurance claim and request payment of benefits be made to Internal Medicine Physicians, P.C.

Print Patient Name

Patient Date of Birth

PATIENT OR RESPONSIBLE PARTY SIGNATURE

DATE

Appointment Reminders

Appointment reminders can now be made by phone call, text or e-mail. Please mark your preference below and list what number or e-mail address would be best to receive this reminder. Unfortunately our system only allows for ONE option, so please pick the ONE you most prefer.

Phone call

Text

E-mail

Name (print)

SIGNATURE

DATE

Contact Authorization

Internal Medicine and Family Physicians, P.C. is committed to protecting our patient's privacy. Without your authorization, messages left on voicemail or with other individuals will be limited. The only information left will be limited to our office name and phone numbers. If you prefer more complete information be provided, please fill out the form below.

Best daytime contact #

Leave message-only provider name and phone #

Leave message-lab/test results, med changes, etc.

I understand that if I have any tests or labs done, I need to be given the results or see them on the patient portal. I will not assume "no news is good news".

Initial:

I hereby give permission to release my medical information to the following individuals:

Authorization Signature

Please sign below to authorize the above contact information. Changes to this form will require a new form to be completed.

SIGNATURE

DATE

Health History Questionnaire

Previous or referring doctor

Date last seen by previous Dr

Pharmacy

Date of last physical exam

Childhood Illness:

Other childhood illness

List your prescribed medications as well as over-the-counter medications (such as vitamins and inhalers)

Name of Medication	Dose	Frequency Taken

Allergies to Medications

Type	Reaction You Had

Policy Acknowledgments

I have read and agree to the Financial & No-Show Policy

I have read and acknowledge receipt of the Notice of Privacy Practices

Final Acknowledgment Signature

By signing below, I acknowledge that I have read and agree to all policies and authorizations above.

PATIENT/RESPONSIBLE PARTY SIGNATURE

DATE

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17030 Lakeside Hills Plaza, Ste 102/130 • Omaha, NE 68130 • Phone (402) 758-5800 • Fax (402) 758-5809

Health Tips from Our Providers

Our Omaha care team shares plain-spoken, evidence-based tips. Like the easiest way to keep blood pressure in check, when to choose a virtual visit, and how to read your own lab numbers, so you can stay healthy between appointments and make medical decisions with confidence.

17030 Lakeside Hills Plz Ste 102, Omaha, NE 68130

Our office is located within Lakeside Two Professional Center, immediately South of Lakeside Hospital. It is easiest to park along the west side of Lakeside Two and enter from the main entrance.