Information For New Patients
We accept the following types of insurance: Medicare and Medicare Supplement plans; Major Medical Insurance, PPO Insurance and State Medicaid. Persons who subscribe to a Managed Care Plan or Health Maintenance Organization (such as United Health Care/Medicare Complete) may not be covered by their plan for some medical services through our clinic. Please contact your HMO customer service representative for referral to an "in-network" provider.
Scheduling an Appointment:
You may schedule your initial appointment in one of three ways:
- Call the clinic intake coordinator, at 402-559-7515
- Complete and send an appointment request form on-line.
- Download and print the appointment request form, then fax or mail a completed form to the fax number or address shown on the form.
The Intake coordinator will speak with you to gather additional information, answer your questions and schedule your first appointment.
After you have scheduled the appointment we will mail you a set of forms and a postage-paid return envelope. Please read the enclosed instruction letter carefully, as it will assist you to complete the forms and direct you what to do with them, once they are completed.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
To arrange for copies of your medical records to be sent to us, we will enclose AUTHORIZATION FOR RELEASE OF INFORMATION forms. You should complete and sign each form as directed, then mail or fax each form to a physician or hospital where you have received treatment in the past 5 years. DO NOT SEND THESE FORMS BACK TO US!
If you need additional copies of the AUTHORIZATION FOR RELEASE OF INFORMATION forms, click on the following link: Authorization for Release of Information
The following link will permit you to pre-register online (provide information such as name, address, contact persons and insurance carriers): Patient Pre-Registration (online)
Please note, the forms you receive by mail will differ, depending upon which type of clinic visit you have scheduled: Primary care, Medical Consultation or Geriatric Assessment. For additional copies of these forms see the printable versions below.
Geriatric Primary Care Clinic:
Medical Consultation Clinic:
Geriatric Assessment Clinic:
- Patient History Form (pdf)
- Collateral Source Questionnaire (pdf)
- Social Work Data Base Questionnaire (pdf)
You will need Adobe Acrobat Reader to open and print these forms. If you do not have the reader you may download a free copy from Adobe.