Release of Medical Forms

You do not need to bring this form to your appointment, however please review:
View our Notice of Privacy Practices
View our Financial Policy

Para pacientes nuevos

Haga clic en un enlace para descargar.

Office visits are by appointment only. We will try to make yours as convenient as possible. Because of the many emergencies in our practice, we may be delayed, or may even have to reschedule your appointment. We apologize in advance for any inconvenience this may cause. Our ultimate goal, however, is to see patients “on time” as we understand your time is valuable.


Payment for office services is expected at the time of each visit if you do not have insurance. An itemization of your charges will be given to you each time you are seen in our office. MasterCard, Visa, and Discover cards are accepted, as well as HSA account cards. If you have insurance coverage we will file your claim for you.

We cannot look to a third party (i.e., auto insurance, liability) for payment of services rendered; therefore, the patient receiving such service is responsible. Any patient who wishes to discuss fees is encouraged to do so with our insurance billing department.

Our insurance department can be reached directly at (402) 399-9301 and will assist you in any way possible. If you have any questions regarding a claim that has been filed, please contact the insurance department.


If you should require hospitalization, we admit patients to Midwest Surgical Hospital, Methodist Hospital, Methodist Women’s Hospital, Methodist Physicians Healthwest, Nebraska Medicine, CHI Health Bergan Mercy, CHI Health Lakeside and CHI Health Lakeside ASC.  Office personnel will arrange your admission and assist in answering any of your questions. Upon admission, your physician will note the plan of treatment on your hospital chart. You may be visited by any one of the physicians in our office.

We will file all insurance claims for hospital services. For care not covered by insurance, financial arrangements can be made with our insurance department.


We participate with Medicare and we will file your claims with them and with one supplemental carrier for all services rendered.


If your coverage is with one of the HMO’s and PPO’s with which we participate, we will file your insurance claim. Any co-payment amount must be paid at the time you are seen. Please bring any required referral forms with you or you will be responsible for your charges that day. A statement will be sent for any balance due, and your prompt payment will be appreciated.

Even through patients have insurance and benefits are payable, the insurance contract is between the patient and the insurance company; therefore, the prompt payment of our fees remains the personal responsibility of the patient.

If you are unable to pay your account in full on receipt of your statement, we ask that regular monthly payments of at least $50.00 or 10% of the balance commence following receipt of the first statement. Accounts are considered delinquent 60 days following the date of service.

Health reports for insurance companies or to attorneys for litigation purposes, claims, etc., require payment in advance.


DISCLAIMER: There may be employer specific plans we are not in network with, so it is best to check with your insurance before your appointment to confirm your office visit will be covered.

In Network Insurances

  • Aetna/Coventry (including CHI and Medicare plans)
  • BCBS NE (Blue Classic, Blue Preferred, Network Blue, all out of state BCBS, Select Blue Choice)
  • Bright Health
  • Champ VA
  • Cigna
  • Corvel WC
  • Dept of Labor NE
  • Elite Choice
  • First Health
  • Humana & Humana Medicare plans
  • Amerigroup – IA Medicaid
  • Medicare
  • Medica 
  • Midlands Choice
  • Multiplan
  • Principal
  • Ohara Work Comp
  • United Health Care 
  • UHC Community Plan – NE Medicaid
  • Nebraska Total Care – NE Medicaid
  • Wellcare of Nebraska – NE Medicaid
  • Tricare
  • Wellmark
  • Iowa Medicaid
  • IA Total Care – IA Medicaid (eff 7/1/2019)
  • VA

Out of Network

  • Health Alliance Medicare Plan
  • Tricare plus
  • Medicare plans from other states